Christine Frackelton, CD(DONA), CBS

I was thrilled recently when a client shared with me her copy of Real Food For Pregnancy by Lily Nichols. Looking at its cover alone makes me salivate, and since I’m going through my 4th pregnancy at the moment, it feels a very opportune time to see what the latest evidence is on diet and nutrition for growing a baby.

Fortunately, I already had some knowledge on the subject from a college nutrition course I took about 16 years ago. From that class I knew that there were additional nutritional needs for the pregnant and lactating mother. However, I also knew that newborns are not usually seen with great nutritional deficiencies even when the mother gets inadequate nutrition, because pregnancy will simply rob the gestating woman’s bones and other tissues of their content in order to prioritize the fetus’ well-being and growth. That nature takes such good care of babies is pretty amazing! However, the idea of emerging from pregnancy brittle and weak sounds awful, especially if the next goal is to continue nourishing this baby with breastmilk, which consumes even more nutrients than pregnancy. This is why access to nutrient dense food and quality information about prenatal and postpartum diets is so valuable.

Enter: Lily Nichols’ book. Her guide was written to inform both practitioners and expecting parents on optimal nutrition, but also goes beyond food advice by highlighting how other lifestyle decisions impact your well being and that of your baby. Don’t be surprised to read about exercise, community support in the postpartum weeks, emotional health, household and skincare products, and more.

Here I am copying the table of contents so you can catch a preview:

• Chapter 1: Why You Should Have a Real Food Pregnancy
• Chapter 2: Real Food Nutrition for Pregnancy
• Chapter 3: Foods That Build a Healthy Baby
• Chapter 4: Foods That Don’t Build a Healthy Baby
• Chapter 5: Meal Plans
• Chapter 6: Supplements
• Chapter 7: Pregnancy Expectations & Common Complaints
• Chapter 8: Exercise
• Chapter 9: Lab Tests
• Chapter 10: Toxins
• Chapter 11: Stress & Mental Health
• Chapter 12: The Fourth Trimester
• Recipe Appendix
• References
• About the Author

Short summary

I’m reluctant to share too much of this book in a blog post, because I fear someone may read my little summary and believe that is enough, when in reality, the whole book is worth the time and effort for pretty much any pregnant person. Please let what I write here merely whet your appetite for the entire book.

That said, if I could boil down her advice to key take aways, it would be to eat a lot of high quality animal products including organ meat, fatty fish, and whole pastured eggs, and complement these foods with non-starchy vegetables (especially leafy ones) and legumes. Enjoy fiber as well as fermented foods which are often richer in probiotics than supplements. Limit your exposure to heavy carbohydrates (especially if you don’t exercise a lot), omega-6 and trans fats, soy, sugar and artificial sweeteners, toxins, and stress, and use strategies to mitigate what exposure you can’t avoid. Exercise throughout pregnancy but come back to exercise slowly after giving birth. Don’t use supplements to justify an imbalanced, nutrient deficient diet, but do know how to supplement smartly, especially if you’re vegetarian, or avoid seafoods, or don’t spend a lot of time in the sunshine. Consider lab tests beyond what your care provider will offer. Build a support network. Continue eating foods that support your baby’s brain development and your own recovery after your baby is born and breastfeeding. Know that small changes in the way you shop for food, cook, and eat can add up to big differences in your health and your baby’s.

If you read the book, you’ll discover in wonderful detail why these recommendations are made, and will probably become pretty passionate yourself about the foods you consume. If I had to sum to book up into a single sentence, this would probably be it:

Real, nutrient-dense food is powerful at preventing health problems, supporting healthy development of babies, and promoting physical recovery, hormonal balance, and mental well being for new moms.

What I loved

There was much to love in Real Food for Pregnancy. I first of all want to express my deep respect for how the author emphasizes evidence-based recommendations and is liberal with her citation to scientific research. It is pretty uncommon to find books written for the public that include 33 pages of references cited in very fine print. If I feel like quibbling with Lily Nichols over anything in her book, I can look up the articles she cited and see for myself where her point of view originates before coming up with any rebuttal. For nerds like myself, this is delightful. For anyone else, you can just enjoy the extra peace of mind that comes from knowing Nichols’ advice is backed by solid evidence.

I also appreciate that Lily Nicols comes across as very sympathetic and humble. Just the thought of 300+ pages full of diet, lifestyle, and parenting advice makes me think of this hilarious pillow design from our local needlepoint shop, Lycette:

Nichols’ strong recommendations for pregnant women are well tempered with her girl-next-door understanding of what it’s like to live real life. She confesses to eating salt and vinegar chips to get though the nausea of her own pregnancy, reassures overweight moms that their diets during pregnancy have much greater bearing on their infants’ health than their diets before conception, and even opens up about her own struggles with trying to do too much too soon after her baby was born. In comparison to another popular food book for women who have just given birth, The First Forty Days by Heng Ou et. al., I found the meal plans and recipes much more approachable for American women, too.

One of the best parts of the book is where the author dissects the conventional diet advice given to pregnant moms and replaces it with more evidence based recommendations. I believe this section will probably liberate many women from the fear of eating “dangerous” foods like sushi, soft cheese, and undercooked egg yolks (when these foods are carefully procured), and could even lead to reduced morning sickness. Similarly, Nichols dispels other food myths and explains why many of the foods we have been taught to avoid are in fact the very things we need to consume when we’re expecting a baby.

There were a couple of surprising elements to me that made the book feel an especially worthwhile read. The first was how disparate pregnant women’s nutritional needs are from what is provided by the sample meal plan suggested for pregnant women by the Academy of Nutrition and Dietetics (formerly American Dietetics Association). This knowledge makes me feel extra compassion for women who have tried so fiercely to eat “right” only to have complications that could have been prevented or lessened with better guidance. When I searched the internet for the original article referenced by Nichols for that sample plan, it seems the plan was written in 2014, so I can hope the meal suggestions from Academy of Nutrition and Dietetics have been modified since then.

The other surprise for me was all of the information Lily Nichols shared about mothers’ thyroid health and how it impacts brain development for babies. I was especially struck when she noted that a mother’s thyroid levels may cause autism (in addition to other neurodivergent conditions). If there is indeed a correlation with thyroid impairment and autism, why is seemingly nobody else making noise about this? So many providers make claims that the cause of autism is either mysterious or can’t be prevented, but Nichols suggests that may not be the case. If she is right, then we have been failing expecting families and we can do so much better. Fortunately, many concrete steps are offered by Nichols to help women get their thyroid levels appropriately checked, balanced, and working to promote a healthy full-term pregnancy and neurotypical growth for babies.

Critique

One of the issues with traditional scientific writing is that authors report data and interpret it from an objective, neutral standpoint, which can be boring and hard to ingest for an everyday layman. Lily Nichols corrects for that by using very approachable writing style and (almost always) clear professional opinions that can be easily applied in real life. Unfortunately, this sometimes come at a cost.

For example, compare her commentary about dietary salt with the section on postpartum thyroid labs.

Salt (pages 22-24):

“For most people, salt does not have an impact on blood pressure. In fact, according to researchers from the University of Virginia School of Medicine, only about 25% of the population is salt-sensitive.”

“To put it simply, salt is your friend — not your enemy — when you’re pregnant.”

Please note that the bold typeface was added by Lily Nichols, not by me.

Postpartum Thyroid (pages 242-243):

“In fact, ‘up to 23% of all new mothers experience thyroid postpartum dysfunction….’ That’s almost a quarter of new moms!”

Please note that the italics were added by Nichols and not by me.

“A surprisingly small percentage of clinicians run thyroid panels at postpartum checkups, and when they do, it’s often not a full panel; reasons for this lack of screening are beyond my comprehension. Ask your doctor to run a full thyroid panel, including thyroid antibodies, at your postpartum check up(s).”

Do you see what she did? She minimized the 25% of the population who probably need to watch their salt intake while placing a huge emphasis on the need for all of us to be tested for thyroid dysfunction even though it affects a smaller 23% of new moms. Though it is “beyond her comprehension” that doctors don’t routinely run full thyroid panels on their postpartum patients, she never even suggests what tests may be available for the greater population of us who may be salt sensitive, and goes so far to make the bold faced comment that we should become good buddies with salt. I wonder if she only meant that for the 75% who aren’t salt sensitive, but since she didn’t explicitly say so, it comes across as a suggestion for all.

I suppose her biases must come from her personal or work experience. Maybe she just has more personal experience working with or knowing people who have suffered from postpartum thyroid issues than cardiovascular events. Whatever the case, it is apparent is that Nichols has placed her personal voice in the book. While it makes the book more fun to read, I do see this as a bit of flaw when it comes to reporting the facts neutrally and offering objective advice.

Another part of the book that I think is imperfect is the section on exercise. The author’s general guidelines (recommending the “talk test”, and providing reasons to exercise) were fine. When she delved into descriptions of exercises you can perform at home, I was less than thrilled. Perhaps this section would be improved with visuals to accompany her instructions. Regardless, I believe it would be better to attend a prenatal fitness class, find a workout partner, or even watch prenatal yoga videos than try to follow her written instructions… which are designed for a person who is sitting down in a comfy reading spot. Thinking about the sedentary activity of reading a book on exercise makes me laugh, even though I’m guilty of doing this many times before. I suppose it’s ok for inspiration, but not as inspiring as new exercise clothes if you ask me.

For a diet and lifestyle book that is over 300 pages long, I was also little surprised and disappointed to see nary a mention of seasonal eating. Without actually mentioning the Slow Foods movement, Lily Nichols promotes almost all of its other ideals — mindful eating, cooking and eating more at home, and procuring animal products from local farmers who use pasture. She touches differences between organic and non organic produce. She writes about differences in traditional cultures’ diets based on what foods were regionally available. She notes how various adaptogenic herbs native to different geographic areas played roles in the traditional postpartum care around the globe, and even brings up our differing vitamin D needs based on latitude and skin pigment. So, why the omission of seasonal differences in food? When you notice in her recipes that she happily opts for frozen produce when it’s out of season, it seems that seasonal dining is not on her radar. This is sad to me, given that produce in season is at peak nutrition, and nature tends to provide exactly the nutrients we need when we need it, such as juicy melons in the hot months when we sweat more.

I really only have one other complaint about the book, and that is its lack of an index. With a book so useful and informative as Real Food for Pregnancy, I prefer to be able to refer back to it and find topics easily. The table of contents and chapters being organized with subheadings are nice, but a well written index is far faster and more helpful when searching for particular little discussion points. Perhaps in a future, revised edition, that will be added.

Conclusion

While there is some room for improvement in Real Food for Pregnancy, I overall felt it was an excellent read, worthy the attention of any practitioner who works with pregnant and postpartum families as well as expecting and new parents themselves.

It should probably also be required reading for public health policy makers. I can imagine things like local Women, Infants and Children (WIC) offices connecting their clients with local farmers who don’t use pesticides, or even FDA regulators changing permissible farming practices and incentives to discourage factory farming and promote pasture based methods instead. Perhaps this book could even inspire revolutions in aquaculture to improve the quality and availability of seafoods. In all cases, the downstream effects can only be positive for our planet’s health… not that the purpose of this book is to reduce global warming. This book is about promoting health for you and your baby, with a focus on nutrition.

Assuming future updates in the scientific literature will lead to revised editions of this book, I really look forward to picking up newer copies and reading this again. Nichols did bring up nutrigenomics — a field of study currently in infancy — which seeks to understand how genetics influences dietary needs. I believe the personalization of diets to one’s individual needs is brilliant, with genetics playing an important role alongside one’s stage of life and physical activity levels. Another more recent topic of research (that Nichols’ did not mention) was how various cooking methods result in higher production of dangerous advanced glycation end products (AGEs). It would be wonderful, for example, to see if scientists find differences in health outcomes for mammals and their offspring who consume fried beef compared to those who consume grilled beef compared to those who consume beef that is slow cooked. Though Nichols has a very authoritarian stance when making food suggestions to her readers, I still feel we have much to learn. I’m curious and excited to see how evolving information in these new areas of study can add to the knowledge Nichols has shared with us.

Until then, stay tuned for other book reviews I’ll share in this space. Do you have a book designed for expecting or new parents that you’d like me to read and review? Please share your book suggestion(s) with me at tremendoulas@gmail.com.