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There is something incredible about pregnancy and the ability of our bodies to literally build and create another human. The biological and physiological processes that occur over the course of a human pregnancy are dramatic and require an incredible amount of energy and nutrients. In fact, research continues to confirm that the foods you eat and the way you nourish your body during pregnancy has a direct impact on your baby’s health, not only in early infancy (1), but potentially for the rest of his or her life (2,3) This is why nutrition during pregnancy is so important. And yet, our healthcare system is not meeting the needs of pregnant and breastfeeding women. Even though women frequently report wanting more nutrition education (4), more often than not, they are given the bare minimum in information and recommendations from clinicians who have minimal nutrition knowledge and training and express a lack of confidence in their ability to provide effective nutrition and weight counseling to pregnant women (5,6,7). Registered dietitians are healthcare professionals that are THE experts in the use of food and nutrition to promote health and manage conditions, including pregnancy, from a clinical perspective. But seeing a registered dietitian is not a part of standard prenatal care in the United States. This lack of coordinated care leaves many pregnant women to turn to google for their information, which can be filled with misleading or fear-based nutrition information, adding unnecessary and additional stress to moms who are just trying to do their best and figure out what they need to do during pregnancy. When it comes to optimal pregnancy nutrition, the amount of information can seem overwhelming, but it really comes down to a few key factors that, if optimized, will set you and your baby up for success. Fundamentals of a healthy pregnancy At the most basic level, optimal pregnancy nutrition does not differ too much from optimal nutrition in your everyday life. You want to choose nutrient-dense foods, meaning foods that have a high level of nutrition (vitamins, minerals, antioxidants, phytochemicals) relative to their caloric value. These foods tend to be things like vegetables, particularly cruciferous and green leafy vegetables, fruits, eggs, salmon and other fatty fish, quality meats, nuts and seeds. Honestly, if you focus on making those food items the bulk of your diet during pregnancy, you are well on your way to eating optimally with few other things to worry about. When choosing meal options, aim to get a protein source at each meal and snack (remember: your body is literally growing another organ and a whole person and will require a ton of protein for that). Also aim for high quality fat sources, which include fats that are higher in Omega-3 fatty acids (important for baby’s neural development). These include foods like fatty fish, grass-fed meats, eggs, nuts and seeds, avocado, and coconut. Micronutrients Micronutrients are the vitamins and minerals that are essential for healthy development and the physiological processes that occur in our body. There are some micronutrients that are of particular importance during pregnancy for various reasons, and many, which increase in need during this time. Those include folate, iron, calcium, vitamin D, vitamin B12, vitamin B6, choline, glycine, vitamin A, vitamin K2, vitamin C, DHA, zinc, and iodine. The majority of these can be obtained through a nutrient-dense diet, as discussed above. The more you eat foods that contain these vitamins and minerals, the less of a need you will have for external supplementation. There are times during pregnancy where it can be tough to eat high nutrient foods, like in the first trimester when you’re dealing with morning sickness and fatigue. At these times and throughout pregnancy, a high-quality prenatal vitamin can be incredibly helpful to cover the gaps in your diet. Fluids In addition to an increased need for nutrients, fluid needs also increase during pregnancy in order to support fetal circulation, amniotic fluid, and a higher blood volume (8). When you’re pregnant you want to aim for about 100oz of fluids daily. I know that seems like a lot. But fluid doesn’t just mean water. That’s total fluid intake for the day. Here are some things, besides water, that count as fluids: smoothies, soups, chilis, and broths, water-rich foods like watermelon, grapes, lettuce, or pickles, ice cream or popsicles, sauces and gravies, and obviously all the other drinks like milk or tea or juice. Supplements Everyone is different and needs are different during pregnancy. It is possible to get most of your needs through a very nutrient-dense diet with food, but that’s not the case for most of us. Generally, in addition to a high-quality prenatal vitamin, some pregnant women may choose to also take a vitamin D supplement and an Omega-3, particularly DHA, supplement. Vitamin D is a really important nutrient that can prevent pregnancy complications and significantly impact the short-term and long-term health of your baby (9). But it’s pretty hard to get from our food and a lot of us don’t get great sun exposure. And studies estimate vitamin D deficiency is high in pregnant women - anywhere from 28-85% depending on where you live (10,11). Because of this, I usually suggest supplementing with Vitamin D. DHA is absolutely essential for healthy brain development in your growing baby. It’s incorporated into the brain, eyes, and protects the brain from inflammation and other damage. It’s possible to meet your DHA needs through food if you’re consuming 2-3 servings of nutrient-rich seafood each week. But many of us aren’t doing that, so a supplement can help. If you are opposed to fish oil supplements, you can take an algae-based DHA supplement. Those are really the main supplements that I have found to be most helpful for pregnant individuals. Others that may be helpful in certain situations are iron, probiotics, and magnesium. Foods to Avoid During Pregnancy The long list of things to not eat during pregnancy, almost always with few exceptions, are because of the risk of foodborne illness from things like parasites or bacteria. When you’re pregnant your risk of foodborne illness increases (12), so it is important to be mindful of good food safety practices and avoid foods likely to harbor bacteria or parasites during this time. Additionally, there are also foods that do not pose a food safety risk, but are also not providing optimal nutrition for you or your baby. Rather than strictly avoiding these foods, it is usually best to limit them as best you can. Below are the foods (and non-foods) I would recommend completely avoiding during pregnancy based on risk and health: Alcohol - no amount of alcohol has been shown to be safe during pregnancy and it will likely affect each of us differently, so it’s best to avoid it. Energy drinks - This is a broad recommendation and perhaps there are exceptions, but they tend to have a lot of caffeine, a lot of added vitamins, and a lot of random ingredients where the safety hasn’t been assessed in pregnancy. High mercury fish - like shark, bigeye tuna, king mackerel, and swordfish. Raw shellfish - 85% of seafood illness comes from eating raw shellfish, basically raw mussels, oysters and clams Undercooked pork, lamb, venison, and ground beef - toxoplasmosis gondii is a much higher risk in these cuts of meat than it is in beef. Soft cheese from unpasteurized milk - it’s 50-160X more likely to cause Listeria infection than when it’s pasteurized. And in the United States, we pasteurize the majority of our cheese, so there are a lot of great alternatives for you to choose from. And these are the foods that I would work to limit - not necessarily avoid completely - but limit in pregnancy. Remember: your goal when it comes to eating in pregnancy is to get optimal nutrients and energy for your growing baby. So with that in mind: Caffeine - stick to the guidelines of under 200mg daily on most days. Refined carbohydrates - they just don’t have a lot of nutrients, so the more you eat, the less nutrition you’re taking in for your baby. They also have a major impact on blood glucose, and can increase your risk or worsen your symptoms of gestational diabetes. Straight refined sugar from sources like soda, candy, and juice. This is for the same reason as refined carbohydrates. Just try to limit the amount as much as possible. Low quality fats (vegetable oils, processed seed oils, trans fats - which will say partially hydrogenated in the ingredient list). The quality of fat can have an impact on cognitive development in your baby, so try to get fat from high quality sources - like avocados, eggs, fatty fish, and quality meat. You might also want to consider taking a DHA supplement if you do not eat a lot of these food sources. Conclusion It is important to point out that these are recommendations for an optimal pregnancy diet. The human body is pretty incredible and even when conditions aren’t optimal, will do everything it can to bring a healthy baby to term. There are a number of things that can happen during pregnancy that make eating optimally difficult or seemingly impossible. For example, nausea, vomiting, and food aversions that are common in the 1st trimester, but can last an entire pregnancy for some women. During these times, the first priority is really to manage the symptoms and accept that you might not be able to eat optimally during that time. And that’s ok. Just make sure to find windows of times to fit in nutrient-dense foods when you can and don’t stress too much when you can’t. Want some help with snack options? Get my free pregnancy snack guide for some great recipes and ideas.

Folate is an essential water-soluble B-vitamin, also known as vitamin B9. It plays a crucial role in cell growth and the formation of DNA, as well as many other roles highlighted below. Folate is a generic term used to describe multiple types of vitamin B9, including: dihydrofolate (DHF) tetrahydrofolate (THF) 5,10-methylenetetrahydrofolate (5,10-MTHF) 5-methyltetrahydrofolate (5-MTHF) also known as L-methylfolate Folate is available from food in its natural form or from supplements or fortified grains and cereals in its chemically synthesized form, folic acid. In dietary supplements folate is generally in the form of folic acid, but it can also be found as L-methylfolate (5-MTHF), which is the biologically active form of folate. I will discuss the studies that look at 5-MTHF and it’s potential to be a better source than folic acid for certain individuals below, but for now, here is a link to the NIH Office of Dietary Supplements, which says this exact thing. Recommended intakes of folate are given in dietary folate equivalents (DFE), which are units that account for the differences in absorption between food folate and synthetic folate in supplements and food fortification. The RDA is 400mcg DFE for women of childbearing age and 600mcg DFE for pregnant and lactating women or 4,000mcg per day for pregnant women with a previous history of NTDs. Importantly, recommendations are not made for folic acid alone. There is nothing unique about folic acid that would suggest that this is the only safe source of folate to raise levels to a place that prevents deficiencies and subsequent neural tube defects in the fetuses of pregnant women. Folic Acid vs L-Methylfolate Folic acid is the stable synthetic form of the vitamin used in drugs, supplements, and fortified foods. It is heat stable and costs much less, so it is the generally preferred form for supplementation and fortification. Metabolically, it needs to be reduced in the body in order to become biologically active. Folic acid has no biological activity unless converted into active folates. The simplified conversion for this is below: Folic acid → DHF → THF → 5,10-MTHF → (reduced by MTHFR) → 5-MTHF 5-MTHF, also known as, L-methylfolate, is the folate derivative normally found in blood circulation (1). It is the active form of folate used by the body. Supplementing with L-methylfolate bypasses the folic acid metabolism cycle because you are supplementing with the biologically active form that requires no reduction (as shown in the simple conversion above). For those with an MTHFR polymorphism, which can significantly reduce one’s ability to convert 5,10-MTHF to 5-MTHF (2), supplementing directly with 5-MTHF can be beneficial (3). Why folate is important in pregnancy Folate is essential for brain development and function. Deficiencies in the general population are known to cause megaloblastic anemia (4), and have been associated with increased oxidative stress (5) and cognitive dysfunction in aging (6). In pregnancy, specifically, deficiencies of folate are known to cause neural tube defects (NTD) in the fetus (7). Neural tube defects include problems with the formation of the skull, scalp, brain tissue, spinal cord, and vertebrae. In 1991, a study was published demonstrating that women with a history of NTD in previous pregnancies who took 4mg of folic acid daily before pregnancy and through the 12th week of gestation experienced a 72% reduction in their risk of recurrent NTD (8). Subsequently, in 1992, the CDC recommended that all women of childbearing age consume 0.4mg of folic acid to ensure adequate levels of folate when pregnancy occurs (9). Finally, in 1998, the FDA mandated fortification of grain products with folic acid (10), which resulted in a 28% reduction in anencephaly and spina bifida, the 2 most common NTDs (11). Bioavailability of L-Methylfolate vs Folic Acid As opposed to folic acid, the bioavailability of methylfolate does not rely on metabolic conversions in the folate metabolism cycle. As such, its intake does not lead to masking vitamin B12 deficiency (12, 13), or the potentially harmful accumulation of the highly oxidized form of folate in the blood (14, 15), which is a risk of folic acid supplementation. Importantly, the bioavailability of methylfolate is also not affected by polymorphisms in the genes that encode the enzyme MTHFR. Polymorphisms in the genes that encode for MTHFR have been identified as a genetic risk factor for NTD (16, 17, 18, 19). Because folic acid does not bypass the conversion that requires MTHFR, supplementation with folic acid could be doing a disservice to individuals who have this polymorphism (3). Although there are no RCTs assessing the effectiveness of L-methylfolate on specifically preventing NTDs (see the last paragraph for why), metabolic studies have shown that L-methylfolate is overwhelmingly effective in improving folate biomarkers, which is the goal of folate supplementation. Multiple studies have shown that methylfolate is at least as effective at increasing plasma folate compared with folic acid (20, 21, 22, 23). And many additional studies have actually found it to be more effective at increasing plasma folate in individuals (24, 25, 26, 27), as well as breastfeeding women (28). Importantly, I did not come across a single study that showed that L-methylfolate was less effective than folic acid at increasing plasma folate levels. L-Methylfolate in Pregnancy A retrospective, comparison study of different forms of folic acid in pregnant women assessed a prenatal supplement containing L-methylfolate or one with folic acid and found that those who had L-methylfolate in their prenatal supplement had significantly higher hemoglobin levels at the end of the second trimester and at delivery (29). A recent article that reviewed the advantages and disadvantages of folate supplementation with folic acid versus methylfolate, with a focus on fetal and maternal health, highlighted several benefits of supplementing with methylfolate and concluded that supplementation with 5-MTHF in pregnancy could be advantageous over that with folic acid, because 5-MTHF is immediately active, does not require metabolic activation, is directly bioavailable to the mother and fetus, and is not influenced by the possible MTHFR gene mutations (30). Another review article (31) looking specifically into 5-MTHF as an alternative to folic acid for the prevention of neural tube defects concluded that “supplementing with 5-methylTHF for NTD prevention seems to be rational. In contrast to the MRC study, testing the efficacy of 5-methylTHF against a placebo would be unethical. Comparing the preventive effect of FA with a proposed better alternative (5-methylTHF) will require following several thousands of pregnancies over a long time. The costs of testing 5-methylTHF against FA would be extremely high. We do not have any reason to assume that a randomized controlled trial is justified before recommending 5-methylTHF.” Final Thoughts I included a direct quote in that last study because I think it is important to highlight the specific justification of why there are no RCTs completed yet and why this does not justify avoiding 5-MTHF or, especially, stating that it could in some way be dangerous. There is absolutely no evidence to suggest this. Research on nutrients and nutrition is often different than research on pharmaceutical drugs and those differences greatly influence the design and conduct of clinical trials as well as their interpretation. We know deficiencies of folate cause the issues I highlight above, as well as NTDs in pregnancy. We know that adequate plasma folate prevents or significantly decreases the risk of NTDs. We know that methylfolate is as adequate, if not more adequate, in increasing plasma folate levels when compared to folic acid supplementation. Therefore, it is more than reasonable, to propose and use 5-MTHF to increase folate levels and prevent NTD in pregnancy.

For as long as I can remember, one of my very favorite things was sitting down in the morning with a hot cup of coffee. I’m not much of a chocolate eater or tea and soda drinker, so my caffeine throughout the day has always come from coffee. After becoming pregnant, it was important to me to understand how coffee could affect my baby, what the current guidelines were, and what the research actually says about caffeine intake during pregnancy. Let’s take a look. Caffeine is a drug that stimulates your brain and nervous system. Studies show that about 85% of the US population consumes at least one caffeinated beverage per day, the majority of which comes from coffee (1). In pregnancy, caffeine crosses the placenta, exposing the fetus to concentrations similar to systemic levels in the mom (2). Research has also linked high caffeine intake to increased levels of miscarriage (3, 4), preterm birth (3, 4) and low birth rate (5). But when it comes to caffeine intake during pregnancy, the research, unfortunately, is not conclusive and is limited by small sample size, confounding factors that don't allow us to assess causality, and retrospective collection of data influenced by recall bias (6, 7, 8). A meta-analysis of 53 studies aimed at investigating associations between caffeine intake and spontaneous abortion, stillbirth, preterm delivery, low birth weight and small for gestational age infants concluded that there was insufficient evidence to change current recommendations of 200mg/d in pregnancy (9). In 2020, a review article, which got a lot of press, looked at 48 studies or meta-analyses on caffeine intake and miscarriage, stillbirth, low birth weight and/or small for gestational age, preterm birth and concluded that no amount of caffeine in pregnancy was safe (5). However the review presented no new evidence - only discussed the evidence that already existed, which was used when making current guidelines for pregnant women. And a large majority of the papers reviewed did not control for confounders such as smoking, maternal age, and alcohol use, which are all associated with higher caffeine intakes and can lead to increased risk of miscarriage as well. With everything taken into account, the conclusion is certainly overstated and guidelines have not changed because of it. What is much more clear is that caffeine intake amounting to about 200mg per day is almost certainly safe during pregnancy. In fact, nearly all official governing bodies, including the American College of Obstetricians and Gynecologists (ACOG) and the World Health Organization (WHO) suggest that caffeine up to 200mg per day is safe (10). That’s the equivalent of about two 8-oz cups of coffee, depending on brewing methods. It is worth mentioning that this is a very conservative estimate. Again, there are almost no high-quality studies suggesting that caffeine intakes above this are harmful or cause preterm births or increased miscarriage. Even ACOG, states that they are unable to find a correlation between high caffeine intake and miscarriage. But for now, until the evidence is stronger, this is the most reliable recommendation that we have. When I was pregnant, I switched from coffee to Americanos, so that I could better assess the amount of caffeine I was taking in each day. Each shot of espresso is equivalent to about 75mg of caffeine, so I had one Americano in the morning and one in the afternoon and never gave it a second thought.

There were a lot of things that surprised me after I became pregnant for the first time. The ridiculously frequent trips to the bathroom starting early in my first trimester, the exhaustion like I had never experienced, and the number of people who all of a sudden felt comfortable touching me or commenting on my body (what is with that?) to name a few. But as a dietitian with a PhD in nutrition, probably the most surprising thing to me was the incredible amount of misinformation, and, I assume, well meaning pregnancy nutrition advice that had little to no supporting evidence or data. Let’s discuss the one that mattered the most to me: sushi. The official recommendation in the United States, contrary to Japan, the UK, Australia, and others, is to avoid all raw or undercooked seafood while pregnant. ACOG even explicitly states “You should avoid all raw or undercooked fish when you’re pregnant” (1). But why? There are really 2 specific reasons for this recommendation: foodborne illness (from listeria, salmonella, or parasites) and mercury poisoning (mercury is a neurotoxin and the fear is that it could harm brain development). Let’s take a look at both. Mercury Poisoning Mercury is a neurotoxin and very high doses in pregnancy can cause hearing, vision, and cognitive impairment in the child (2). Since the Minamata incident in Japan in 1956 (3), the public has become increasingly aware and concerned about environmental pollution affecting the seafood supply and the resulting negative health consequences. While some fish are actually quite high in mercury, many, even most, fish are perfectly safe to eat during pregnancy, not only because they are low in mercury, but also because the fish contain high levels of selenium, which binds to mercury and prevent it from doing damage to the body (4). In fact, research consistently shows positive effects of regular fish intake during pregnancy on children’s IQ, communication skills, fine motor skills, and cognitive abilities (5, 6, 7, 8, 9). The best predictor of mercury content is the size of the fish, so if anything, you may want to avoid large amounts of some tuna, swordfish, shark, tilefish, marlin, orange roughy, king mackerel, and marlin. But there doesn’t appear to be any reason, with regard to mercury, to avoid fish like salmon, whitefish, catfish, cod, haddock, hale, trout, and many others (Use the guide here). Foodborne Illness The main reason sushi is considered an off-limits food during pregnancy is because of the risk of foodborne illness. However, flash freezing, which is done to the vast majority of restaurant-grade sushi, is effective for killing any parasites (10). Furthermore, seafood for human consumption undergoes screening for microbial contamination, thus increasing safety. And even more, if you actually look at the data of foodborne illness in the United States, raw fish is not even one of the highest contributors. A recent CDC report that assessed food sources of foodborne illness from high priority pathogens (including salmonella and listeria) showed that for salmonella, 38% of all cases were found in vegetables and fruits, and eggs and meats made up nearly 40% of all cases. And for listeria, 50% of all cases came from fruits and 31% from dairy (11). In fact, studies suggest that nearly 50% of all foodborne illness in the US comes from produce (12). And yet we’re not asking women to give up fruits and vegetables during pregnancy. The more you look into the data on foodborne illness, the more you start to realize how arbitrary some of these recommendations really are. There is a cost to these recommendations to avoid fish too. The nutrients in fish are incredibly beneficial to pregnant women and their babies. Fish contains omega-3 fatty acids, important for babies brain development, and many incredibly important vitamins and minerals, including vitamins D, B6, and B12, iron, iodine, zinc, and selenium. Not to mention, it is an excellent source of protein. To reiterate the benefits explained above, in one study of over 12,000 mother-infant pairs, more than 12oz of fish consumption was strongly linked to childhood IQ and communication skills, and mothers who ate no fish during pregnancy had children who were more likely to have problems with fine motor skills, social development, and communication skills (13). When I was pregnant, I researched the heck out of this topic because I love sushi, but I also wanted to make sure I was doing everything I could to keep my baby as healthy as possible. For me, the data and recommendations didn’t add up and the benefits of eating fish, outweighed the potential negative effects. I ate sushi occasionally from reputable restaurants that I went to before getting pregnant without ever getting sick. As with everything, you get to make the best decision for you and your baby, but I do think it’s important that we have the correct information to make educated decisions when it comes to our health.

Breast milk is pretty amazing stuff. In fact, there are numerous cognitive, immune, digestive, and metabolic benefits of nursing, both for you and your baby. For the mother, breastfeeding is associated with lower postpartum cholesterol and triglyceride levels, decreased postpartum blood loss, lower risk of maternal anemia, and prolonged lactational amenorrhea (delays the start of your menstrual cycle after birth), which comes with its own set of benefits (1,2) In the long-term, women who breastfeed have a reduced risk of postmenopausal hypertension, diabetes mellitus, hyperlipidemia, metabolic syndrome, cardiovascular disease, rheumatoid arthritis, and stroke (3,4,5,6). Additionally, breastfeeding was associated with a 22% reduction in the risk of breast cancer and a 30% reduction in the risk of ovarian cancer (7). For the baby, breastmilk confers many additional benefits that can impact the child throughout their entire life. Specifically, breastfed infants are reported to have a diverse and healthy gut microbiome, fewer colds, diarrhea, and ear infections, and reduced incidence of obesity and other chronic diseases later in life (7). With so much to be gained from breastfeeding, more and more moms today are choosing this option for their babies. But it is important to understand the challenges that can come with breastfeeding, as well as the nutritional demands that breastfeeding places on your body. There is a lot to be said about the challenges, emotional stress, and other realities of breastfeeding, but in this post, we’ll focus specifically on the nutritional demands and considerations for mothers who choose to breastfeed. Diet and breast milk connection A mother’s breast milk provides all of the nutrients that her baby needs to thrive. Research shows that even when women are not eating optimal diets, they still produce nutritious milk full of immune-boosting antibodies and important nutrients for their baby. In fact, certain important nutrients are virtually unaffected by maternal nutrition (likely designed to help babies survive even if their mothers were undernourished) including calories, protein, folate, and most trace minerals (i.e. calcium, iron, zinc, etc). Other nutrients, however, can pass through to breastmilk and are directly affected by the mother’s diet, including nutrients important for brain health. This is why it’s important for breastfeeding mothers to try and eat as nutrient-dense and optimally as possible. Calorie needs to produce breast milk Caloric needs for postpartum women vary depending on a number of factors including weight gained during pregnancy, maternal energy stores, activity level, and genetics. Generally, a mother’s body uses about 300-500 calories per day to produce breast milk, so increasing caloric intake with nutrient-dense foods to match this is advised. Food and nutrients to increase or emphasize when breastfeeding Water When breastfeeding, you’re going to be thirsty. So thirsty. Breast milk is more than 80% water, which means your body is going to need more of it. There is no perfect recommendation here in terms of exact numbers, but the best recommendation is to drink water consistently throughout the day and actively try to increase the amount you drank prior to breastfeeding. Foods high in B-vitamins and choline B vitamins (with the exception of folate) directly impact the nutrient quality of breast milk, so it is important to prioritize b-vitamin-rich foods. Some great options include green leafy vegetables, eggs, organ and grass-fed meats (particularly for vitamin B12), eggs, and legumes. Foods high in fatty acids and DHA The quality of fat that you eat directly impacts the quality of fat found in your breast milk. Look for sources that are high in DHA, including seafood (i.e. salmon, tuna, trout, and cod), as well as other non-fish sources of omega-3 fatty acids like flax seed, chia seed, hemp seeds, and walnuts. Vegetables and fruit We have been told to eat our fruits and vegetables our entire lives, but no time in a woman’s life is more important to take this advice than while breastfeeding. Fruits and vegetables are a rich source of nutrients, including vitamins, minerals, antioxidants, and phytochemicals that can all enhance the quality of your breast milk and subsequently the nourishment of your baby. Many, including carrots, spinach, sweet potato, and tomatoes, are specifically great sources of vitamin A, which passes through to a mother’s milk. A note on food allergies While it is important to eat a diverse and varied diet while breastfeeding, there are a few foods that you might want to consider avoiding while breastfeeding. You’ll want to keep an eye on how your baby is responding to your breast milk and assess if he or she might be allergic to something you are eating that is passing through to the milk. The most common allergens to watch for are milk, eggs, peanuts, soy, wheat, and fish.