#203 | Pre-eclampsia: Diet, Nutrition and the Influence of Sperm with Lily Nichols

I've seen certainly a few dozen cases of preeclampsia across a couple of 1000 couples. And they're typically told as Americans are told when it comes to cancer, it's totally out of your control, which is zap somebody and there's nothing we can do about it, which is absolutely ridiculous in the case of preeclampsia, and cancer and so many other things. So I'm just eager to hear what you've learned about nutrition and its relationship to preeclampsia.

And when you start looking at the various micronutrients and the roles they play in preeclampsia, I mean, you just run down the list, like there's data on almost every single one, especially your minerals, specially the minerals, so like so we do now know that protein requirements are way higher than we previously thought in pregnancy. So hitting that sort of brewers diet recommendation of around 100 grams, even more for really active women seems like a really wise choice.

I'm Cynthia Overgard, owner of HypnoBirthing of Connecticut, childbirth advocate and postpartum support specialist. And I'm Trisha Ludwig, certified nurse midwife and international board certified lactation consultant. And this is the Down To Birth Podcast. Childbirth is something we're made to do. But how do we have our safest and most satisfying experience in today's medical culture? Let's dispel the myths and get down to birth.

Hi, everyone, I'm Lily Nichols. I'm a registered dietitian and diabetes educator focused on prenatal nutrition. You know, I've been on the show once before. So you may have heard my intro, but the short and sweet of it is I have two books, real food for pregnancy, and real food for gestational diabetes. And I think you've brought me on to talk about preeclampsia today.

Yes, that's correct. We had you on for episode number 155 and gestational diabetes. And that was a huge hit. Everybody loved it. And we are very interested in speaking with you today about what we can do as far as diet and lifestyle to help reduce prevent reverse any, any or all of the above as it relates to preeclampsia and pregnancy. Yeah, it's a hot topic. One of the things that we've noticed is that many mothers in late pregnancy are labeled as being preeclamptic, when they might just be sort of borderline as far as you know, blood pressure is getting a little bit of hot, a little bit high. And maybe they have some protein in their urine. But it seems to be a reason for inducing mothers sometimes unnecessarily, obviously, sometimes not. But so could you just start off by giving us giving us a little bit of definition on preeclampsia, and then you can go into your research on it.

Sure. So I think preeclampsia sometimes gets lumped into or confused a little bit with other hypertensive disorders of pregnancy. So there, there can be high blood pressure, and pregnancy also called hypertension. That occurs without somebody also being diagnosed preeclamptic. So with preeclampsia, you have the high blood pressure plus the protein in the urine. But you can have gestational hypertension without the protein in the urine. And it seems like sometimes the diagnosis gets a little bit mixed up with some clinicians. I mean, having worked in conventional prenatal care, I was specifically at one point worked in an office where we trained like OB GYN residents, you realize that a lot of mistakes happen. Lots of people get their terms and definitions mixed up. I think that does sometimes happen with preeclampsia. Nonetheless, the treatment or what helps to reduce the severity potentially, is really pretty similar between the two whether it's considered preeclampsia, or just some other form of gestational hypertension. And we can go into that.

What I noticed with preeclampsia is that the symptoms get confused for the definition and the diagnosis. And almost anywhere you turn when you asked what preeclampsia is it always comes down to those two symptoms happening in tandem. But what it's been so hard for me through the years and upon researching it to go deeper than that. I mean, at one point I read well, I know that giving birth is what resolves it. I mean it does become more serious through it. It only happens typically in the third trimester. It's increasingly progressive. It's often a good reason for induction and giving birth is the resolution and the risk is to the beat to the mother's life not to the baby His life. However, upon researching it further, it's so hard to find out what exactly is happening in the body. I mean, I know that seizures can occur, which they'll treat with magnesium sulfate intravenously I, I've read that it can potentially result in liver failure though I don't know if that makes sense to a nutritionist like you I would love to hear if that sounds reasonable to you. Um, do we know any more about it Trisha, anything else about preeclampsia, we can talk about beyond the symptoms before we go deeper on this? Well, I think part of the problem with preeclampsia is that we don't really understand exactly the root cause of it, it does seem to be something that is established actually, the risk for developing it is established early on in the placental development. I don't know that that means that you absolutely are going to get it you you know, there may be things that you can do or not do that may make you more likely or less likely to get it but once it kind of takes hold it in the differences that preeclampsia involves other organ systems, whereas you know, gestational hypertension is just high blood pressure, but their organs involved. As time goes on in the pregnancy, it gets worse and worse and worse. And delivering the baby ultimately is the resolution of it. But you also still don't can have postpartum preeclampsia. So yes, and that's a fascinating topic. So that's how Sybil died and Downton Abbey.

Oh, really? She died after giving birth of preeclampsia and Downton Abbey? Yeah, yeah. It's not an immediate resolution, it's still the baby, it protects the baby. So, you know, we get we get the baby out so that the baby is not at risk because of the mother has seizures, which is what we're trying to prevent when a woman becomes preeclamptic that magnesium is used to treat the seizures or prevent the seizures not or could be treated, but it's used to prevent and that protects the baby and the mother and then you still have to keep an eye on the mother postpartum.

Right, right. Yeah, it's it's, I think what makes preeclampsia so interesting is that we don't have perfect answers on what can prevent it 100% And what causes it 100% The symptoms do indicate that there's some sort of dysfunction going on with the lining of the blood vessels. And in some case, that in itself can lead to organ damage, there's definitely, you know, higher rates of oxidative stress. So maybe like the antioxidant systems in the body are not working as well as they should. Or there's, you know, other things going on triggering more oxidative stress such as like, also having high blood sugar, for example, like blood sugar and blood pressure tend to go hand in hand, the more blood sugar you have in your bloodstream, and you know, the more insulin resistant you are, generally you're just going to have more proteins and things in your body, including the lining of your blood vessels go glycated essentially, like sugar coated, which makes them dysfunctional in and of themselves.

That's a really interesting point, because we know that gestational diabetes also originates in the placenta. And then something about the connection there. If you have gestational diabetes, the risk of preeclampsia is much as Yes. But we also know that we can really through diet, lifestyle, nutrition, we can really reduce the severity of gestational diabetes, or potentially even prevent it or reverse it, their sense that there's things that we can actually do to help reduce the risk of preeclampsia. Yes,

before we go there, Trisha, you mentioned and I think Lily, you concurred that they can sometimes tell if a woman is at risk early in pregnancy. How what do they see? What would they tell her? What exactly can they see early in pregnancy?

Well, I want to before I jump into that, I want to circle back to something before I forget, which is something that I observed when I was very young dietician working in prenatal care, which was I was mainly doing gestational diabetes work, but I'd also have women with preeclampsia, you know, referred to me in the clinic, and when I do a diet history, so these women's I wasn't seeing them already, right, because I'm already handling all the women with gestational diabetes. So I do a diet history. And I learned like their diet was like, I remember one very distinctly there was one who would drink like two large containers of orange juice a day and would eat through like sleeves upon sleeves of saltine crackers using the word sleeves. So you know, those come in those big huge boxes and it's just, it's just a white flour product. You know, there's like not much going on there. Probably her body was begging for extra potassium and sodium. But as you can imagine her blood sugar was a nightmare. So she had passed, you know, her glucose screening, because sometimes you do get, you know, false negatives on that. Or, you know, her body truly can handle high carb loads without having consistently super high blood sugar right to like pass the threshold of the test. But her diet was like completely imbalanced. And so I actually found in practice that just just the the scenarios that would show up and I'm not saying this is true of all women with preeclampsia, of course, because some very well balanced diet, and it still happens to them. So I don't want to paint this broad stroke that all cases are like this. But my experience in that clinic, it was was pretty consistent that there was like, imbalanced dietary intake, low nutrient density, low protein intake, and usually a pretty excessive, simple carbohydrate intake going on. And that's kind of what made me start making connections with. Okay, I already knew there was a blood sugar blood pressure link. But wow, a lot of the same interventions that we use nutritionally for gestational diabetes, actually worked really well for preeclampsia as well, just just correcting for some of those, like gross imbalances that that I would see gross meaning large, not gross, disgusting, using medical terms here. Now, I'm forgetting the point, the question that you had for me before I went on my tangent, so could you repeat that?

That was very important. So thank you for addressing that. My question was, what can they tell by the placenta in early pregnancy? And how is it an ultrasound? Trisha made a reference to something earlier? And you seem to understand what she was saying, but I didn't? What can they see in early pregnancy that could tell if a woman is going to be predisposed to preeclampsia?

Yeah, I mean, so there's a lot of studies that look at like maternal, I think they usually call it metabolic omics. I hope I'm not messing up the term but looking at what's happening in bloodwork to see what could be potential risk for preeclampsia. So signs of oxidative stress, higher homocysteine levels, which are indicative indicative of higher levels of inflammation and often some nutrient deficiencies. Sometimes low level levels of minerals can be indicative. There is, it does seem to be at least some lines of research are pointing to something happening with early placental development. So the placenta develops in the first trimester kind of finishes developing towards like the beginning of the second trimester. And there is a massive increase in the formation of blood vessels, right. So like the placenta connects, like, penetrates the uterine wall and is the way that nutrients and hormones and blood and all the things are exchanged from the mother to the baby. So this is a huge interface of vasculature. And if that early like the called angiogenesis, like formation of new blood vessels doesn't go very well. those blood vessels, there might not be enough of them, they might not expand and contract as much as they should, it can simply impair the flow between mother and baby and seems to potentially play a role in the development of preeclampsia or the risk factors for preeclampsia. So anything that's going to be impairing the formation of those blood vessels potentially could be a risk factor. There's even some very interesting research on the role of paternal, like DNA from paternal sperm and the development of preeclampsia. So the placenta is very interesting because it you so you can look at the genetic makeup of the placenta actually expresses a higher amount of paternal DNA than maternal DNA. And so there has been some studies suggesting that like, whatever's going on with the Father and unhealthy sperm, if dad has poor nutrient status, poor methylation, potentially, that could impact the health of the placenta. And of course, we've heard maybe you've heard women who have babies for multiple partners, and sometimes you'll have somebody who had, you know, preeclampsia and her first two pregnancies with her first partner, and then her third pregnancy where you'd think, Oh, well, now you're older and all the risk factors for all these things go up and you have this history of it. Suddenly, there's no development of preeclampsia. So like, what's going on there? That's, I think, where they they initially got really interested in looking at the paternal factor.

I just want to say it's about time. Yeah, right. Father, we've all learned our whole lives that like sperm is always good. It's always is healthy, it's always hard that the dad could be 90. And in any state of health, and the it's always on the mother, like make sure you're living a healthy low stress, nutritious lifestyle, but it's how can we ignore this children come out? Yeah, half their fathers, they can look like their fathers, how do we just totally dismiss that? What begins as one cell from each parent like one just doesn't matter and one and like all the stakes are on the other. So I'm very happy to hear they're finally opening that up, because now it's going to open up research into a whole host of other knowledge on what can be coming from the paternal side. One of the main risk factors for preeclampsia is a new partner. That's like top.

I know, but what you that see, I never would have, I never would have thought about why See, that's interesting. And there are so many things that are risks to women that have to do with the her number of partners like GBS, and then you just think in terms of, you know, health or infection or STDs, but it really could be the paternal component. Just one follow up to that very simple one. You're talking about the vasculature and all of that, how can they see that? Because any pregnant woman listening is going to be like, Oh, my gosh, is that me? Or my or my? Or the vessels? All Okay, between my placenta and body? Would a blood test show that alone or a blood test combined with ultrasound? You mentioned blood tests, but is there anything? No, how do they know that?

I'm not entirely sure how you would check that. I know, in later pregnancy, you can measure like blood flow via the umbilical cord, right. I'm not sure how they would know that. And in early pregnancy or not.

I don't think it's a regular screening?

I don't think so I think it's something maybe that's looked at in research studies, but not widely available, like with your neighborhood about the bloodwork, you know that that is important. And those tests that you mentioned in bloodwork aren't also are not even routinely screened for in a first time.

I think my purpose for maybe bringing up some of this early pregnancy information is that even if you have been trying to like stack all the cards in your favor and and avoid it, sometimes it could have been something that happened like, hey, maybe, maybe it's the sperms fault. First of all, maybe it's something that develops so early in pregnancy, before you even knew you were pregnant, potentially by factors that aren't within our control. And so sometimes later on when we are, you know, worried about our blood pressure rising or potential diagnosis, we want to kind of beat ourselves up on Oh, my gosh, I all did all these things wrong. And this is all my fault. And if only I'd known and even if you are super on top of things, sometimes it is just sort of a situation that that develops even with our best intent. So I don't want people to be super hard on themselves, because, you know, the research is still ongoing. So if if we had all the answers, I'm like, Oh, you do these five things, and you will 100% all the time prevent the development of preeclampsia. That'd be wonderful. But we're not at that point. Yet.

For years that I've been working with couples, I've seen, certainly a few dozen cases of preeclampsia across a couple of 1000 couples. And Bear typically told as Americans are told when it comes to cancer, it's totally out of your control. It's just zap somebody and there's nothing we can do about it, which is absolutely ridiculous in the case of preeclampsia and cancer and so many other things. And I always found it interesting and noteworthy that ina may Gaskin basically reduced preeclampsia down to zero or virtually zero with the same number of clients as I've, as I've known. And she she is very strict about diet when women went to give birth at the farm very strict. It's my understanding she put them on a vegetarian diet, their primary drinks had to be water, not juices, not milks. So I'm just eager to hear what you've learned about nutrition and its relationship to preeclampsia.

Yeah, yeah. And I think part of it amaze success, too, is, you know, there was that community aspect too. So in terms of reducing stress, I mean, compare that to the average American. I think that had a big a major factor and just removing the processed foods. Just simply removing the processed foods and removing stressors, and not having to like, fight with the medical system that's trying to sabotage your birth. Hey, that reduces your stress a little bit too, right. So yeah, nutritionally, I already pointed out the my observation really early on in my career, about imbalanced dietary intake. And usually there was a high intake of refined or simple carbohydrates that I observed in the clients that had preeclampsia or any type of type of gestational hypertension. And in situations where there's sort of an obvious like, Oh, this is imbalanced, I find that it's easy, it's pretty easy to make a difference in their blood pressure pretty quickly, just by shifting the macronutrient balance a little bit. One of the biggest ones for me is increasing the amount of protein. So it's one thing to just be like, cut back on the refined carbohydrates, but what are you eating in its place? And we don't have a ton of data on protein and preeclampsia. But certainly we have, you know, the work of Dr. Brewer, everybody knows the Brewers diet. Turns out that a lot of his recommendations have come to be true by the modern research. So his suggestions on eating a high protein diet on eating more salt? That certainly does that seem to pan out in the literature as helping. So we do now know that protein requirements are way higher than we previously thought in pregnancy. So hitting that sort of bruise diet recommendation of around 100 grams, even more for really active women seems like a really wise choice. We do have a small case control study that found that low protein intake was associated with an increased risk for both preeclampsia and eclampsia, we're waiting on some larger trials, we do know that there's certain amino acids that seem protective against high blood pressure. Glycine is a big one, I talked about glycine, a lot in real food for pregnancy. This is a very small amino acid that plays a direct role in the production of elastin, which is a you can kind of guess by the name elastin. It is part of the lining that makes up your blood vessels that allows them to expand and contract appropriately. We know that glycine is an amino acid that becomes conditionally essential in pregnancy. So by our current understanding of it outside of pregnancy, you can probably make all the glycine you need from other amino acids. I don't agree with that. But that's the conventional understanding of it. In pregnancy, we know for sure it becomes conditionally essential, you have to have a reliable dietary source of it. And a lot of women show signs of glycine insufficiency, which you can measure by a urine biomarker. Glycine insufficiency is more common in women with preeclampsia. Glycine insufficiency is more common among women who are eating low protein and also women who eat a vegetarian diet. So you're glycine rich food sources are your collagen rich foods, which are your animal foods that have a lot of connective tissue like if you make bone broth or you have a tough cut of meat that like you know, you can't just like throw it on the grill like a steak or chicken breast and it's tender enough to cut With a knife and fork, like you have to slow cook this in broth or liquid for many, many hours for that to soften and break down. And then also the skin of any animals. So if you're making like chicken, for example, the whole idea of pulling off the skin because it's the least healthy part of your chicken, it has so much fat oh my gosh, that is outdated, arguably harmful advice because that is a very, very rich source of glycine. For pescatarians if you eat like the skin on your fish, so if you're doing like salmon filets, eat the skin, if you want to, like cook it a little longer, like take the skin off and cook it till it's crispy. So it's a little more desirable, you could do that there's, you know, collagen supplements, which could be another option to get more of this amino acid. But I have found that just simply increasing the protein intake and especially highlighting those collagen rich foods to get the glycine and take up does wonders for for people's blood pressure, like sometimes you see it come down pretty remarkably quickly. And then the other thing I just want to throw in there is that, you know, our protein rich foods are generally our most micronutrient dense foods as well. So they have the most vitamins and minerals. And when you start looking at the various micronutrients and the roles they play in preeclampsia, I mean, you just run down the list, like there's data on almost every single one, especially your minerals, specially the minerals so like Selenium is a big one. You know, Selenium is functions basically as an antioxidant in our system. And it also helps with the production of our body's innate major antioxidant glutathione. Selenium seems to really help that's super rich in fish. Of course, our fish also has like many of our omega threes we know that is helpful with blood pressure both in and outside of pregnancy. So start checking the boxes,

is that also true for vegetarian sources of protein, chickpeas, lentils, even Kimani aren't those also very complex in their nutrients and minerals just for the vegetarians out there, they would also be providing you certainly can get your protein intake up from those sources as well. They are not rich sources of glycine. And they're not rich sources of selenium. So for vegetarians, your best option for selenium would actually be Brazil nuts. And then as far as like balancing your amino acid intake, I mean, your best option is to get as many as large of a variety of amino acids as possible. So a large variety of like your legumes, your nuts and seeds, grains, hopefully in whole form. And I'm not a huge fan of soy but but fermented soy products like tempeh A, which is also a lower carbohydrate option, but like a very low processed soy option can be a good option as well. And if there are animal foods coming in, like your eggs are a very, very good source of selenium, they would be the only vegetarian source of DHA with the exception of algae based DHA supplements. And eggs can really help balance the amino acid profile. And I'll just add, like just one more note on that topic, if somebody is eating vegetarian protein needs probably need to be at least about 20% higher for vegetarians, given the imbalance and amino acids, so you'll have to work a little more diligently to get to even higher, I would go higher than 100 grams a day. The other thing is, since all of your vegetarian sources are also a source of carbohydrates, it can be a little bit challenging to keep, like the macronutrient ratio in you know a favorable place for blood pressure regulation. So sometimes there's a case for supplemental protein in those situations, and you can do of course, plant based options, you know, there's like rice protein and pea protein and I would argue for maybe a blend of some of the options again so we're aiming for amino acid balance. But there's there's a case for that just definitely make sure you're getting one that's third party tested for heavy metals because the the vegetarian vegan proteins tend to be the most likely to be contaminated because some of the plants just rapidly uptake, heavy metals out of the soil like rice and arsenic. So just a caution on that.

Rice is not a particularly healthy option in my mind one of those plant based rice products but it was never like a prouder fan because it's just, I'm not buying your furniture. It's um it's by nature. It's processed by you, but I hear your argument that sometimes you just have to go the extra mile to get more protein in one way or another?

Yeah, I mean, this is a very long conversation, I have another book coming out. Hopefully in the next year, we'll see where there's going to be like a whole chapter on vegetarian diets and, and you know, the the key points of consideration. In so insufficient protein and excessive intake of carbohydrates and like imbalances in fatty acid intake favoring high omega six, low Omega three, there's lots of situations that kind of work against you when it comes to the blood pressure stuff, some of which can be mitigated with careful planning. But things like inclusion of eggs can be really helpful. Again, like for reasons beyond what we've already covered, but like choline intake, is has been shown to reduce the risk of preeclampsia significantly, and choline for vegetarians, especially the number one source would be a Gilkes. So and then you'd be getting that amino acid balance. So it depends on the severity of restrictions in the diet and how willing somebody is to work with these things. But those would all be, you know, things that I would be considering.

Lily, are vegan women and vegetarian women being counseled. Do you know are you aware of they are being counseled about increased risk of preeclampsia and pregnancy? Or is that panning out in the data that we're seeing that

I have not seen a study yet? That's that's stratifying, you know, dietary intake that specifically on preeclampsia risk, a lot of them are looking at specific nutrients, kind of going nutrient by nutrient but not like dietary rising type. Yeah. So, you know, that's just a little bit. That's something that we need more data on.

I bet the biggest thing that moves the needle is the processed foods and those carbohydrates. You were talking about the sleeves of Crassus. I think that's just got to be the biggest factor probably.

Yeah, so you know, women with gestational diabetes, for example, have like a one and a half fold higher risk of developing preeclampsia. And that's because of that situation of high blood pressure and high blood sugar kind of going hand in hand as well as you know, higher insulin levels tending to drive up the inflammation as a whole. We do know, you know, high intake of refined carbohydrates is a major risk factor for preeclampsia. We have data from pretty large study groups, like one study I'm thinking of had almost 33,000 pregnant women and those who ate the most added sugars were the most likely to develop preeclampsia.

And is that just in pregnancy, or six months prior to pregnancy a year prior to pregnancy? What would you advise women as far as like reducing their carbohydrate load?

Yeah, I mean, specific to that study, you'd have to go back and open the study to see how far back they did a dietary survey. Usually they're catching them when they're pregnant. And they're asking them to recall retrospectively what their diet was like, I don't know how far back that went off the top of my head. But my opinion given that we know there's some risk of you know, early, early issues with placentation being a potential factor in the development of preeclampsia, I would ideally like to see the reduction in sugar intake and like choices towards better quality carbohydrates and more like glycemic balanced meal plan. I would hope for that to take place preconception. The earlier that happens, the better. And we know that like a lower glycemic index diet favoring higher protein intake works especially well for those that are at an increased risk for you know, blood sugar insulin issues, like women with PCOS, for example. And there's also just higher fecundity, so like chances of conception, like the chances of conceiving are greatest in women who have the lowest blood sugar levels and when they start to creep up towards pre diabetic levels, but even not technically diagnostic of pre diabetes, you see a fecundity drop down. So just for like preparing your body for a really healthy pregnancy, supporting egg quality, lowering oxidative stress, like it makes sense for both partners to be engaging in this sort of preparation time before pregnancy, I think that's where we would see our you know, biggest impact.

Blood sugar seems to be just at the root cause of all health issues. It's just like balancing your blood sugar is so essential to preventing treating, curing fixing every, every part of the body, it seems like there's a lot going on. And our bodies, especially in pregnancy really work overtime to keep our blood sugar's low. I mean, they run about 20% Lower naturally in pregnancy. And our body really works to try to maintain that for, for good reason when it's going too high, and too often, you just see aberrations and so many other systems in the body from our like our stress regulation, our hormone levels, how cells interact, how well our brain works. I mean, it's placental function, it's wild.

Where does magnesium and vitamin D come into the picture? Because women are, I think women often are told or it's true, or it's panned out in the research that magnesium low levels of vitamin D and magnesium are risk factors.

Yep. And actually, they kind of are nutrients that go hand in hand, because the, you know, Vitamin D has to go through a lot of different metabolic transformations in the body and every enzymatic step, but involving vitamin D, has magnesium as a cofactor. So you really need the two of them together. For vitamin D, specifically, there are some proposed mechanisms of action. So we know vitamin D deficiency is associated with endothelial dysfunction and issues with your vascular health. We know vitamin D can help with calcium homeostasis, calcium seems to help lower blood pressure, so there's a link there. And then vitamin D might suppress the, the, the hormone renin, which your renin aldosterone, angiotensin system does play a role in in blood pressure control, as well as like our fluid balance. So a lot of times in preeclampsia, you see a significant amount of swelling or edema, like too many fluids or like fluids in the wrong places. So and that also kind of goes back to the protein too, because you need that protein for that vascular integrity to you know, sort of keep the fluids where they're supposed to be.

That's why the swelling, too. Is that why the swelling happens with preeclampsia?

Yes, generally, yes.

Why do the severe headaches or blurred vision happen? Is it what what in particular, do you think that's linked to?

I think that's related to the high blood pressure. Yeah, so limiting limiting blood flow to essential places, yeah. But also electrolyte imbalances as well. So with vitamin D, for sure, we have a lot of studies linking vitamin D deficiency with preeclampsia. the more severe the vitamin D deficiency, the greater the risk. We know supplementation with vitamin D is associated with like a 63%, reduced risk of the development of preeclampsia. And the greatest risk reduction is seen when supplementation is started before 20 weeks of pregnancy. So earlier, not later. So there's quite a lot of research on on vitamin D. with magnesium Of course, like if, if things are getting really severe, sometimes women are hospitalized and given IV magnesium sulfate. In an effort to prevent like eclamptic seizures, we do know, low serum magnesium is associated with a significantly higher risk of preeclampsia. Both had mid pregnancy and towards the end of pregnancy. We don't have quite as many trials on supplementation, we do have some showing oral supplementation can reduce the risk of preeclampsia, not necessarily severe preeclampsia. And there have been a number of trials that have combined magnesium with other nutrients such as calcium and magnesium, calcium, magnesium, vitamin D, and zinc all together in a supplement does seem to reduce it. So there might be also some like nutrients synergy between some of the nutrients as well. Certainly worth a try. Because most most of us, especially pregnant women are not getting enough magnesium, it's pretty safe thing to give a try. And you can even take magnesium glycinate where magnesium has been bound to glycine and you're getting the benefit of both. It's also a really well tolerated well absorbed form. So that's certainly something that I feel like should be on the table more often. It's it's simple, safe, pretty inexpensive, easy to try out.

Most humans are deficient in magnesium just in general because it's very depleted in our soil and it's very important cofactor for so many processes in the body. What would you suggest as far as levels for vitamin D or red blood cell magnesium if a if a woman wanted to get her bloodwork done and check to see if she was deficient in vitamin D, do you have a threshold that you recommend or vitamin D the the evidence to date on pregnancy seems to point to 40 nanograms per mil as being sort of a minimum threshold for sufficiency and has been specifically linked to reduction in certain issues. For example, there was one study where they supplemented all the women with vitamin D, and they correlated their vitamin D levels with the risk of preterm birth. Of course, that's a risk factor with preeclampsia. And those with vitamin D levels above 40 nanograms per mil had like over a 60% reduced risk of preterm birth. I know outside of pregnancy, there are other researchers who promote like a larger, wider and higher range for sufficiency like maybe 50 to 80 nanograms per mil, I don't necessarily see any harm in doing that. But I would, you know, conventionally our threshold is like 30 or 32 nanograms per mil, and technically they put deficiency at 20 nanograms per mil like, we should, at least in my opinion, be aiming for 40. For that, as far as a red blood cell magnesium, I do not have reference ranges to pull from off the top of my head on that one, I'd need to look into that more deeply. But that definitely could be something to consider. And you'd probably just see deficiency across the board. I mean, like, literally, it's over 60% of, of women of childbearing age in the US are not meeting dietary magnesium intake thresholds. And it it is, you know, I'm all for real food and optimizing how much of nutrients we get from food first, but magnesium is a really, really tricky one to hit the mark on from diet alone, partially because of what you discussed, with like soils being more depleted than they were before. So that is one where I feel like supplementation makes a lot of sense. Lilia, just what are your final easy takeaways for anyone listening, and I know you referenced salt earlier. And one observation I've always made is every midwife I've ever known and respected strongly recommends both table salt and sea salt because of the minerals. So you agree that both salts are necessary and beneficial. And just any final tips or recommendations you have for listeners?

Yeah, so quickly on the sodium This is probably the biggest point of contention. In the prenatal space, especially in nutrition. The conventional advice is to limit yourself intake when you have high blood pressure. And this holds true for what they recommend for preeclampsia as well. But there's been a number of studies that have found that that is actually outdated and unfounded advice, it does not necessarily result in lowering blood pressure, it does not necessarily prevent nor treat preeclampsia, and there has been some data showing that it can actually make preeclampsia worse. So we have some very old studies actually where they, they called it toxemia. Back then, where they actually specifically supplemented women with more table salt, they had to measure out their salt at the beginning of the day and get four heaping teaspoons full. And that resolved the so called toxemia. So I find that you know, mineral needs including sodium increased substantially in pregnancy. Sometimes when people are cleaning up their diet to reduce the processed food and now cooking from scratch, they're not adding enough salt to their food to make it flavorful. Like if you actually cook like a chef, they add quite a bit of salt. So season your food to taste make it taste good. If you notice you're craving a lot of salty foods like chips and pickles and olives and things like that. I mean honor that. But you also probably need to be a little more intentional with your salt intake. On top of that your other minerals as well. So don't forget about like your potassium rich fruits and vegetables, your avocados and bananas and potatoes and prunes and whatnot are also helpful. You need a lot of minerals in balance. So I'll leave you with that. For people who want the data I do write about this in chapter seven of real food for pregnancy. But to kind of wrap up my final thoughts. Definitely we need to be thinking about blood sugar balance and macronutrient balance for preeclampsia. So upping the protein being more intentional about high quality carbohydrates, pushing out as much as you can the white flour products and the sugars or just sugars that have been isolated from their whole foods. So choose, you know whole fruit instead of juice just to keep that total sugar intake down and certainly focus on your mineral intake Especially your salt. We talked about magnesium, we talked about calcium, we talked about zinc, we talked about Selenium, I mean, all of the minerals seem to be helpful. And your vitamin D levels as well you may have to specifically request to have those checked. And it is well worth having them checked because you might be surprised where where you're at on that. We know a lot about preeclampsia. We're learning more every day but we don't have all the answers we don't have the magic bullet where you do all these things and you will for sure prevent it or reduce your blood pressure or whatnot. So you know, take what you learn here implement what works watch how your blood pressure responds but also don't beat yourself up if it's not responding as much as you'd like to see it.

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