#287 | Lily Nichols on Fertility, Folate and Food

If there is one best place to begin when it comes to optimizing our fertility, it is with food, and who better to bring us the lowdown on what we do and don't need for fertility optimization than Lily Nichols, RDN, the modern-day-author and guru of all things related to food and pregnancy. In today's episode, she delivers crucial information about how our modern food practices, particularly the standard American diet, set us up for sub-optimal fertility and contribute to the most common complications of pregnancy including pre-eclampsia, pre-term labor, PPROM, and more. She opens our eyes to the significant problems with folic acid in our food sources, prenatal vitamins, and birth control, and we get into the nitty-gritty on the difference between folic acid and folate. Additionally, she explains which macro- and micronutrients we need to best support the female body for conception. If optimizing fertility is on your mind, this is a must-listen, must-share episode!

Lily Nichols on Folate:  Why it’s Superior to Folic Acid for Pregnancy (even if you don’t have MTHFR)

Lily Nichols on Instagram

And check out our episodes with Lily Nichols:

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

#155 | Gestational Diabetes Prevention and Management with Author Lily Nichols, RDN, CDE

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Transcript

There's no biological role for folic acid in the human body. It has to be methylated. First, they found in the folic acid group a much higher rate of miscarriage, pregnancy complications, preeclampsia, pre prom, preterm labor. And in the methyl folate group, you saw the opposite. You saw a lower risk of miscarriage in pregnancy complications, including preeclampsia, lower risk of pre prom, preterm labor, and three fold more had a full term pregnancy compared to the folic acid group. I want to tell women that they should stop taking their prenatal vitamin if it has folic acid in it. I mean, they're already getting bombarded with it in their food. So we are potentially, especially these moms who are having fertility issues, which is, you know, the the audience we're talking to today, they are being bombarded with really high levels of this, and it potentially has serious consequences, and it's certainly not helping them.

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, I'm Lily Nichols. I'm a registered dietitian, certified diabetes educator and author of three books, real food for pregnancy, real food for gestational diabetes, and my most recent book, real food for fertility. And we're going to talk about fertility today.

Yes, we are so happy to have you back on the podcast. We've had you on two times already to talk about preeclampsia and gestational diabetes. Those episodes are number 203, and number 155, so is wonderful to be talking about fertility, because this seems to be just an increasingly common challenge for women and not men. So we are very eager to hear what you have learned in all your research and what you can share with our community.

Yeah, I mean, infertility is on the rise. It's, you know, approximately one in six couples these days. And think a lot of people think of it as a women's health issue, it certainly is, but up to 50% of infertility cases have a male factor involvement as well. So we need to be thinking about both partners here. Do you think it's a good idea for women to start planning to conceive with just the optimism that it's all going to go beautifully and just have fun conceiving, because that's normally where I'm coming from. Just go enjoy, see how it goes, and if we're coming from that perspective and we want to be as healthy as we possibly can, I think my first question is, what time period Do you think women should really consider getting their health and bodies and nutrition in order before Seeking to conceive and is detoxifying priority above nutrition.

Yeah. So the I get this question all the time, how long should I think about, you know, optimizing things before conception? And, you know, I think it, it really depends. We actually give a couple of different ranges in the book, depending on what you know, lifestyle and history, health history is going on. So if we think about, you know, bare minimum, we can look back to how long it takes a human egg cell to fully develop prior to ovulation. So if you go all the way back to when it's recruited, as you know, an underdeveloped ovarian follicle, you're going back seven to eight months, and then the last approximately three months right before ovulation, is when that egg is very particularly sensitive to nutrient insults, toxin exposure, things like that, optimal, yeah, probably eight months. Then beyond that, we're looking at, well, what's going on with you health wise. Have you already had some you know, health challenges, menstrual cycle irregularities. Do you have polycystic ovarian syndrome? Have you maybe been on hormonal contraceptive, contraception? How long have you been on birth control? Because birth control can affect hormonal birth control anyways. Can affect nutrient levels in your body. It can disrupt mineral metabolism. It can deplete you of certain micronutrients, including folate and other B vitamins. So for somebody who has been on hormonal contraceptives for a long period of time, and also depending on why they were put on them in the first place, we might want to think about a longer like run up period before pregnancy. So for example, if you aren't we're on hormonal. Contraceptives for like, 10 years, and you were put on them because of cycle issues. Right? A lot of times, obese will put you on HCS to regulate your cycle. It doesn't do that. It simply shuts down ovarian hormone production and ovulation, but there was already a cycle issue beforehand. Now, when you come off of it the time that it'll take your body to get ovarian hormone production back on board and get ovulation back on board, and get all your menstrual cycle parameters to a normal place. That can take nine months. It could take a year. It could take 18 months. So you might want to give yourself a longer period of time knowing that your body has some healing and nutrient replenishment to work on before conception. Otherwise, we have women coming off the pill thinking, I'll just get pregnant right away that first cycle. It's like, well, there were cycle issues beforehand. Now we're like, older and all these other things are going on. Maybe we need to give our body a little bit of TLC before we expect it to happen right away.

And when you are referencing hormonal contraception in this way, are you talking in particular about the oral contraceptive pill, or do you think this is the same for women who have like a progesterone releasing IUD ? It's any type of hormonal contraceptives. The Depo shot shot is actually the one that gives you like the the longest time for your cycle to recover after you come off of it. But we go into the like, average time for the cycle to return and normalize in the book, actually in the birth control section of the book. So it depends on which one you're on, but there's any of them that are hormonal contraceptives are going to affect ovarian hormone production, and there's going to be a lag time before the cycle comes back, before you start ovulating. And can you let us know what nutrients hormonal birth control diminishes the most?

Yeah, so a big one is folate. This is why some of the contraceptives actually have, like folic acid added to the birth control pill, not my favorite version of folate, but nonetheless, like it's it's acknowledged to the point that the pharmaceutical industries have responded by fortifying them with that some of them also add iron to it, because it can deplete iron stores. It can affect a number of different B vitamin levels. Vitamin b6 is another one, and it can disrupt mineral metabolism. So some of the minerals that drives the levels down, some of them, it can drive the levels up. You look at something like the copper IUD, for example. Sometimes that can lead to a copper toxicity issue, but nonetheless, there's a disruption to some degree of mineral metabolism.

What metrics are used to determine when everything is normal? Again, like you're saying, it's it's specific based on the birth control if women are on hormonal birth control to begin with, it's specific to what they're on, but it can a woman tell when things are back and Okay, is it just by, is it just on basis of her period being normal again, and then she knows basically all the underlying factors regarding her hormones are back to normal, and presumably some of those nutrient levels are back to normal. Or are there, like, did research come up with this, and are there really deep underlying things that a woman would never possibly know of.

So when you're talking about like the menstrual cycle parameters, those are things that, if you're using, like fertility awareness based methods, you could monitor that on your own. So you could monitor your cervical mucus, or some people call it cervical fluids. You can see whether you're ovulating or not. You can track the length of your bleed. You can track the length of your cycle so time between periods. You could track basal body temperature, which can be used to confirm ovulation after the fact. You could use op case have their pros and cons, but ovulation predictor kits could also be used. You could measure hormone levels. You can measure, we see differences in AMH levels, for example. So this would only be if you're actually measuring this, but you'll see AMH levels will be abnormal for a period of time until ovulation starts to happen more frequently, even measuring endometrial thickness, which is usually only done for women who are undergoing IVF, being on HCS will thin the endometrium over time. So it takes time for that to build back up. You would be able to have a proxy of your endometrial thickness by how much you're bleeding during your cycle. So are you having like a typical, normal menstrual period? And we go through the different parameters that you can look for and what constitutes a normal menstrual cycle. In the book, I believe it's chapter, I don't know, chapters six through eight, I think, go through all this different information on the cycle and tracking and the pill and its effect. On fertility. So you could have like, kind of a clear proxy to look at as for like nutrient levels. Really, the only way that you'd be able to track that would be, like comprehensive lab testing. So, you know, there's a handful of tests that your practitioner could order, certainly checking in on like iron status or anemia, could be something that is done, you know, conventionally, likewise, checking folate status via red blood cell folate or B 12 status via serum B 12 or methylmalonic acid or other other, you know, side markers of it, like homocysteine. But if you wanted, like, a comprehensive look at your micronutrient status, you'd probably be working with a functional practitioner and ordering like a full nutrient panel. That brings me back to the question that had slipped my mind, which was about the difference between folic acid and folate and methylated folate, and what women should actually be taking and is fortifying food and prenatal vitamins and birth control with folic acid even helpful.

Yeah, this, this is a highly controversial topic, and I've been, you know, knee deep on the controversy ever since I wrote a really detailed article going into the folate versus folic acid situation. So the the key thing to know is that folate is an umbrella term. It refers to any type of folate, whether it is naturally occurring in food. And there are 150 different types naturally occurring in food. The most common one is methyl folate, or if it's a synthetic type of folate, which is folic acid, you don't find folic acid in the environment. It is only lab created, man made, and that is the one that is fortified into refined grains, and it's also the default one in the majority of prenatal vitamins and multivitamins on the market, there is a difference in how our body metabolizes them. So for a very long time, everyone's like folic acid is the best. It is stable, it is absorbed super well. We have this data on neural tube defects. It's the best thing ever, and it is absorbed well, but our body doesn't necessarily metabolize or utilize it well, which is important to know, in order for your body to be able to use folic acid, it has to methylate it into methylfolate. As I already said, methylfolate is the main type of folate found in the food supply. Although there are, as I said, 150 types at least, that we know of, it is also the type that is found most in our bloodstream. So 95 to 98% of the folate in our body, circulating in our bloodstream, in umbilical cord blood, anywhere in our system, or our baby systems, is methylfolate. And so it's silly to me that it even is like as controversial as it is, because you'll, you know, there are some very loud actors out there who really hate when anybody talks about the benefits of anything other than folic acid. But at the end of the day, it is more difficult for your body to metabolize and put to use, and some people have genetic differences in the function of the enzyme that controls for methylating folate, called MTHFR, where they really have trouble utilizing it. So you can give them super high doses of folic acid, which is actually very commonly done with reproductive endocrinologists, they'll put you on like 5000 micrograms of folic acid. Note that the tolerable upper limit for this is 1000 micrograms, by the way, so five times the like upper limit, they'll give you huge amounts of folic acid. And we still don't see improvements in folate status. And sometimes you actually see worsening issues with things like methylation, as evidenced by elevated homocysteine levels, which is a marker of inflammation. High homocysteine is a very strong risk factor for recurrent miscarriage, for example, because it doesn't solve the problem. And there's case study reports where you switch those women to a more reasonable dose of methyl folate, and suddenly their folate status improves, their homocysteine normalizes. And, you know, they can get pregnant. So we really have to be, you know, looking at the biochemistry of this, I think the people who are, like, 100% folic acid is the best thing ever. Just have kind of like a tunnel vision on the information they're willing to take in and they they don't seem to be willing to look outside of that box.

Wouldn't it make sense that methylfolate would be better in the body, considering that that is the the way it is found in food, right? Wouldn't that make that just sense?

I was going to say that because it just seems like such a no brainer. One of them is a chemical copy of the molecule, and the fact that there's a controversy makes no sense. There are things that are legitimate, difficult controversies out there really legitimate controversies. This one sounds like the quote, unquote controversy we had 20 years ago about whether a baby benefits from getting all of his or her cord blood. I mean. Right? What I'm hearing from you is there really isn't a controversy. It's simply the people who are denying that what we need is the naturally occurring folate, methyl folate, that occurs in food and the body responds to metabolizes better, right? Like there's not, from your informed perspective, there's not actually an argument for folic acid. It's just the people who are denying that it isn't the best thing, because they're just, you know, locked in that old 1990s major push in the media for folic acid to combat in the 1990s that was when they did a lot of this research on folic acid. So we have these randomized, controlled trials on, you know, folic acid. We have, you know, quote, unquote, good data on folic acid as a whole. Fortifying the food supply with folic acid, as they started doing in the 1990s did to some degree lower the rate of neural tube defects, because if you have a bunch of people eating Ultra processed carbohydrates that don't have any type of folate whatsoever because it was removed in the processing, you now have a, you know, population wide folate deficiency. Better than nothing, right, exactly. And we can metabolize some folic acid about 200 to 300 micrograms, maybe per day, which is the amount, by the way, that the average American woman is getting from her diet alone, not even including any prenatals or supplements or anything like we're hitting that mark. Okay, it still doesn't prevent all neural tube defects, though, up to 30% of neural tube defects are what they call folic acid resistant, meaning this person had sufficient folate status, but and they were taking in folic acid, and they still had a baby with a neural tube defect. Because, for some reason, even though we don't know the mechanism by which folic acid seems to help prevent neural tube defects, it does probably through methylation, by the way, what it does to some degree, and yet it isn't effective in every single case, and that's because there are innumerable factors that affect the risk of neural tube defects. Elevated maternal blood sugar affects the risk deficiencies in all of the methylating nutrients, methionine, B, 12, b6, inositol, choline, glycine, I can keep going, are all related to a higher risk of neural tube defects, and we know we can improve folate status with a variety of different forms of folate. So the fact that they are only focusing on this one form as the end all be all again, I think these people haven't taken nutritional biochemistry and actually thought through like exactly how this metabolism is working out. I also don't think they have any knowledge in the functional medicine space or checking in on more comprehensive lab work to see, are these clients given super high doses of folic acid actually tolerating it well? I mean, a lot of them, you'll drive up folic acid in the body, but it's what's called unmetabolized folic acid. You have this folic acid that's doing nothing. There's no biological role for folic acid in the human body. It has to be methylated first. Okay? And we have this situation where, in some studies, up to 95% of pregnant women have elevated unmetabolized folic acid levels, and we don't know what that is doing the body. There's also questions raised about that as well. So, yes, it is silly. So, so that was my next question. Do we think that there are some risks to having these elevated levels of folic acid? I mean, we've obviously talked about the risks of having deficiency. And by the way, folic acid, or folate, is a B vitamin, correct, it's in the falls in the B vitamin category, correct, okay. Just to make that easier for people to understand, everybody's always like, What the heck is folate anyway? Like, what is it? Give it a letter, yeah. Just make it more digestible. Literally, yes. So do we think there are risks to having excess folic acid running through the body. So it does seem that at a certain level, when you have an excess of folic acid, it can actually interfere with the whole process of methylation. So the whole metabolism of folate and a number of different B vitamins and amino acids can be disrupted when there's an excessive amount of folic acid. So that's a consideration. There have been concerns raised as to whether it might be related to an increased risk for brain development issues such as autism, although we don't have causal data, there's been associational data from some of the research. There's even been questions this goes, like literally, all the way back to when I was in my undergrad. There were questions being raised about increased risks of cancer, specifically colon cancer, because the folic acid is readily taken up by the cells lining our whole intestinal GI tract. And if there's any precancerous lesions, it seems like when they're exposed to folic acid, which helps, like stimulate cell growth and replication. Like, maybe it is like promoting the growth of these precancerous lesions into full on cancer. Again, that still is something where I don't think we have causal data, but we did see a significant uptick in the rates of colorectal cancer following the mandatory fortification of the whole refined grain supply in the US. So we have questions, right? It's like we don't have clear answers, but it's like we may as well, in my opinion, we may as well use the form of folate that we know the body can metabolize, that we know is the major form that it prefers to keep in circulation, and both mom and baby is the major form we find in food. It just only makes sense, but it is far more expensive for supplement companies to use that form. Methylfolate is a little more of a delicate molecule. So in terms of putting it into foods that are then going to be think like bread, right? Put it into flour you bake the bread. Is the methyl folate going to survive the baking process and still be usable by the body. And then, of course, the cost of it being so much higher, that's, that's some of the major, you know, pushback against using it. So I definitely knew some of the things that you said about folic acid, and you know that it really isn't as effective as methylated fully. But now, now you're making me feel like I want to tell women that they should stop taking their prenatal vitamin if it has folic acid in it. I mean, they're already getting bombarded with it in their food. So we are potentially, especially these moms who are having fertility issues, which is, you know, the the audience we're talking to today, they are being bombarded with really high levels of this, and it potentially has serious consequences, and it's certainly not helping them, and it has risk. So this is, this is really important information.

Yeah, I think, I mean, we don't want to create a folate deficiency issue. So if somebody is really not getting enough folate rich foods, and they're not eating any refined grains that would be fortified with it, I'd rather have them on a prenatal that has folic acid then have a folate deficiency. But if they have the option to be getting whole food sources of folate and a prenatal that has better metabolized forms of folate, that's always going to be my preference, because that's what the body can more easily metabolize. You know, as for the concerns over, you know, fertility and pregnancy and all that. I don't know if you saw I put out a research brief on my Instagram. It's called methylfolate versus folic acid for women with recurrent miscarriage and MTHFR. So these are women who had, you know, a genetic variation in their MTHFR genes, so they don't utilize folic acid well. And they looked at women who were either given high dose folic acid, 5000 micrograms a day, or a methylfolate supplement at 1000 micrograms per day throughout the first trimester. And then outcomes were looked at at the end of their pregnancy. And they found in the folic acid group a much higher rate of miscarriage pregnancy complications, preeclampsia, pre prom, preterm labor, and in the methylfolate group, you saw the opposite. You saw a lower risk of miscarriage. In pregnancy complications, including preeclampsia, lower risk of pre prom, preterm labor, and threefold more had a full term pregnancy compared to the folic acid group. People will argue about the study, it's only 100 women, blah, blah, blah, right? But if we don't have companies like, there's no incentive for people to do more research on this, right? And so that, like, we have to work with the data that we have. What I've seen with clients myself is, you know, improvement in their folate status when they switch to a type that they can actually metabolize. We see lower homocysteine levels. I see a quicker time to pregnancy and better pregnancy outcomes. That's my anecdotal clinical experience, but that is mirrored in in the data that we have thus far. It's just common sense. We just have to not forget our own common sense that we are biological. Food is biological. We are meant to eat food. The molecules that come into our body through food are obviously what our body is seeking and looking to recognize and assimilate. I just it's so frustrating that this is even a controversy. It's so frustrating that doctors don't study nutrition, and they could read about this in their free time, like you do. So that's frustrating. So I mean, I just I don't think women need to spend tons of their time researching this when their common sense says, obviously their body is looking to get nutritious food. I did hear your point that if a woman is so poorly nourished that she is still better off getting the chemical concoction, the chemical molecular copy of folic acid, rather than absolutely no semblance of folate in her system, because the risks are more present to have absolutely none, rather than the synthetic folic acid. But obviously, when the choice is available, and really. Why shouldn't it be for most anyone? Obviously, go for the folate. So before we move on from this topic of folic acid and folate, which foods would you say have the most folate in them that women can look to get into their diets?

So the top three, the 3l liver, legumes and leafy greens have the highest concentrations of folate. From there, you're looking at things like, let's see asparagus, beet greens, sesame seeds. I mentioned legumes, but really a whole array of different legumes. So all the different types of beans and lentils are pretty rich source easy, yeah, those would be the major ones. I was just gonna I was gonna say exactly the opposite. I was going to say these are not easy foods to get into your diet for the average person like, not to make really easy what? I'll forget, liver, greens, leafy greens. Yes, leafy greens. Easy. You know, that's really spinach, especially really high asparagus, broccoli. So getting those green, dark green vegetables in the diet will help think about Mexican food. Get a side of beans or make like a lentil soup? It really is in there. You also get some in egg yolks and other animal foods. It is possible. It definitely is possible. The meal plans I have, like in really, any of my books, all of them have meal plans. Those all provide more than the RDA for folate, all from whole food sources. But you know, as a population, we have a really high intake of ultra processed foods, right? 58% of American calories are coming from ultra processed foods. In those foods, the only source of folate you're going to be getting is the fortified folic acid, right? So as a whole, take any micronutrient, take your pick. The more we eat whole foods and displace the ultra processed stuff out, the better off we are with our nutrient status.

I also just want to reiterate one thing you said before and point out that you mentioned all of the things that we are struggling with in maternity care today, preterm birth, neural tube defects, preeclampsia what gestational diabetes? I think you said that too. There was one other one, miscarriage, and miscarriage and increasing rates of autism in children. All of these things are happening at the same time that folic acid has become like so mainstream in the diet and forced upon women and their prenatal vitamins at very high levels. So interesting food for thought and but let's move on from folic acid and folate and talk about other nutritional deficiencies, the most common things that are putting women at risk of having difficulty getting pregnant. So what are like the top nutritional deficiencies that contribute to infertility.

So this one will sound funny, because I'm not going to focus on a micronutrient here, but it kind of captures many protein most women are not eating enough protein. The typical RDA for protein for women equates to like 45 to 55 grams of protein a day. It is not enough. And there have been protein researchers calling out the importance of higher protein intake for well over a decade. Our needs are probably more like double what the RDA is, or maybe even more than that, particularly for active women. And if we hit the mark for protein, we're going to hit the mark for a number of other micronutrients of concern that also affect fertility, iron, zinc, vitamin B, 12, folate as one of them, choline, vitamin A, and a number of different amino acids that have some specific roles in supporting fertility and also improving pregnancy outcomes, like creatine, carnitine, taurine, glycine and so on. So that's a big, major one that I find has, like, the biggest impact is increasing protein intake among women is huge. It's also really helpful for anybody who has, like, blood sugar, insulin dysregulation issues. So like you know, the most common fertility challenge among women is polycystic ovarian syndrome. The majority of cases of PCOS have some degree of insulin resistance, and in some women, it's quite severe insulin resistance, and that there's so many studies on dietary interventions for PCOS, and almost all of them focus on some degree of like shifting the macronutrient ratios, typically increasing the protein and decreasing the carbohydrates a little bit. Again, the studies are to all varying degrees of, you know, higher protein, lower carb, but it's highly effective. Some of these studies are showing it just as effective, or even more so, than putting them on typical like Metformin or other medications that they're using in these populations. So protein is huge. I can go into some of the individual vitamins or minerals, if you want me to, though I want to add to that, even if a woman is not diagnosed with PCOS. Right? Which is, you know, you got to have a pretty disrupted menstrual cycle. I feel like before, actually, a woman gets that kind of diagnosis, but there's a lot going on pre PCOS that can that can impact fertility. Would you agree that, like, there's a lot of pre insulin resistance, or mild insulin resistance, they may still be having normal periods, they may be ovulating, they may not have polycystic ovaries on ultrasound, yet, it could still be impacting their fertility.

Absolutely, yes, and we actually have data. There was a study done out of, I believe it was Singapore, over 750 women who were actively trying to conceive, and they found that women with higher blood sugar levels were more likely to have menstrual cycle irregularities, and they were also more likely to have a delay in conceiving in any given menstrual cycle. And this association was true even in women who had blood sugar at kind of the higher levels of the normal range, so they wouldn't qualify as pre diabetic or diabetic, but just a slightly higher level was associated with delays in conception, and that's because higher blood sugar levels drive up insulin resistance, they drive oxidation, they drive, you know, lower egg quality. They can affect, you know, the whole quality of the menstrual cycle and ovulatory process, reproductive hormones. They're all interrelated. So, yes, protein as a whole everybody. But even more so for somebody who has, like, a known blood sugar issue, is the reason that it's good for those with blood sugar issues, that protein takes longer to digest than carbs. That's part of it. It also simply does not drive blood sugar levels up at all.

This is just a fun question. I'm just, this is just what's going through my mind. What's your theory? Because I don't think there's going to be research on this. What's your theory for why breast milk has such low protein? All we have are theories. But I just thought it's a fun question. It's, I'm always mulling this over in my own mind, so I'm so I mean, you know, I think there's babies are born like fat adapted. They're born in ketosis. So breast breast milk has a pretty decent concentration of fat. It also has a decent amount of lactose, and then a lot of the carbohydrates are actually human milk oligosaccharides, which are indigestible except by the they feed the bacteria in the infant's gut. And so I think it's possible that it's simply a matter of trying to, like, drive the development of the fetal or neonatal, I should say microbiome development possibly, but also like the concentrations of different macronutrients, like that shifts at different stages of development. So like the macronutrient breakdown of colostrum is distinct from mature breast milk, which is distinct from breast milk that a toddler might be taking in. So it does shift at different stages.

I would also add to it that infant growth is so rapid, they have to grow so quickly, and Carbohydrates provide the fastest form of energy. So because they're growing so quickly, they need a higher proportion of carbohydrates to protein in order to do that, when you stop growing and you get older, then you don't need so many carbohydrates, but you need more protein, because your muscle mass starts to break down over time too, and you need to have protein to keep in balance. So just the ratio shifts based on your growth needs.

I thought you needed the protein to build the muscle, because we have so much growth, the most growth in the first Yes, you do, but the proportion of growth that probably because they grow so fast, the proportion of growth that has to happen at a speed, right, versus like, it's, I'm sure it's in proportion correctly for babies to grow at the most effective pace, right?

For women who've already given birth, what evidence do they have if they did have sufficient protein? Like, what do we see in what do we see in the women who have insufficient protein in pregnancy? What are they at risk of? Or what's the evidence of that in the babies after they're born?

Well, we do see a higher risk of complications like preeclampsia, which can drive preterm birth and low birth weight babies, right? That's kind of like all interrelated. Even outside of the preeclampsia sphere, we see increased risk for intrauterine birth restriction and low birth weight babies just as a whole, you can see lower bone mineral density. Even protein does help with bone mineral density. That's that would be like the main thing you see just a smaller a smaller baby as a whole. You also might see a higher risk of certain micronutrient deficiencies, simply because our protein rich foods are so nutrient dense. So you might see, you know, higher rate of iron deficiency or B 12 deficiency or choline deficiency, again, because you're. Usually seeing those micronutrients concentrated in our protein rich foods, we have quite a bit of data on like the that birth weight and infant growth neonate or fetal and neonatal growth based on on maternal protein intake. So we have some protein foods that have all of the amino acids that we need, right? If you look at protein, you have to break it down into the individual components that make up the protein, which are amino acids. There's 20 standard amino acids, nine of them are considered essential, although there's actually no scientific basis for the concept of non essential amino acids that came out a couple years ago. If we're looking at foods that are complete proteins that have the full array of all the amino acids you are looking at animal foods, so meat, fish, eggs and dairy, those are considered complete proteins our plant foods, you know, beans, legumes, nuts, seeds, would be incomplete proteins. We know that if you take a number of different incomplete protein plant foods and combine them together, you're probably going to hit the mark for the nine essential amino acids there. You just won't get certain so called non essential amino acids because they're not present in those foods, or maybe not present in sufficient concentrations. Then you have to look at the protein quality. So this refers to, like the balance of amino acids in different foods, the digestibility of the protein to release the amino acids for absorption, and then How available are those absorbed amino acids for protein synthesis.

When you said non essential amino acids in quotes, you're saying that that's kind of a bogus term. Those amino acids are absolutely essential. They're just considered non essential. Because why?

So the idea is that certain amino acids your body does not produce on its own, those are considered essential, the non essential amino acids our body has the metabolic capability to produce these amino acids from other amino acids. So they called them non essential, meaning you don't have to get them from your diet. Just like we have some nutrients that are essential you have to get from your diet and some nutrients that are not essential you don't have to get from your diet. It turned out that the basis, the whole scientific basis for that, was not actually scientifically proven. And now, in the last 20 or so years, we have different ways of actually specifically measuring amino acid oxidation in the body, and they can see that our body's endogenous production of these so called non essential amino acids is actually not adequate to meet the human body's needs for optimal health. Lily, what other major areas did we not touch on that your book covers with respect to fertility and preparing to conceive? What other major tips do you have to just throw out there? And then, for more information, everyone can read what you have in your book. But let's just, let's just mention what those are, if you wouldn't mind.

Yeah, well, I mean, it's a huge it's a huge book. It's like, over 500 pages. So there's a lot going on. We've just kind of touched on maybe two or three of the chapters that are in it. So there's a ton of information on nutrition, specifics, on digging into the macronutrients and micronutrients, nutrient rich foods, all of the controversies that I seem to have brought up on the non essential amino acids or considerations with plant based diets. We have information on egg quality and sperm quality. Each of those have their own chapters going into the specifics. I think the information on the like sperm quality guidelines is particularly fascinating, like the, you know, bar keeps getting lowered and lowered and lowered over time. So what is truly optimal is a lot more than what a typical clinician will call as a cutoff of, oh, we have, like, a fertility issue with this man's sperm quality.

Wow. They keep lowering it, huh? They keep lowering it. They're normalizing this path, trend right cutoff keeps lowering.

Yeah. So we have, we actually have a chart in the sperm quality chapter showing how those guidelines have shifted since, I believe, the 1980s so they've come way down. And so we really need to be talking more about sort of the delineation between infertile sub fertile, where, like, pregnancy is still possible with this sperm, it's just kind of unlikely, and it's going to take a really long time, and then, you know, optimal fertility. So, yeah, that chapter is super fascinating. We go into like, you know, age related effects on egg quality considerations with like AMH testing, we have a whole chapter on PCOS, a whole chapter on hypothalamic and menoria.

Last question, if a woman who was concerned about her fertility status were to go get some blood work done, maybe she's not seeing a fertility specialist yet, or maybe she doesn't have a naturopath, maybe she's just going to her midwife or. OB, can you give us, like the top five, must do blood work tests outside of hormones, we know, estrogen, progesterone, prolactin, thyroid, like that kind of stuff. But nutrient tests that she should ask for? Okay? Or otherwise, nutrient or otherwise? Yeah, definitely checking out. Like your blood sugar and insulin. Preconception is optimal. I would check both blood sugar and insulin. I would check the thyroid for sure. So underactive thyroid, hypnobirthing is super common in women and also very undiagnosed. It is also a major risk factor in miscarriage and recurrent miscarriage. So we want to optimize thyroid function as best as we can preconception. So identifying that super important. I would say checking overall, like levels of inflammation, homocysteine, is one way that you could check on that that also gives you a proxy on like your folate and B 12 status. If those are sub optimal, you may see elevated homocysteine levels. So that's an important one. And then as far as micronutrients, I mean, it gets it gets tricky, just based on what labs you can get from, like any standard OB. So if you're talking from functional medicine perspective, I would do a full micronutrient panel. If your doctor is not doesn't have the skills or resources or doesn't know anything about that, I would, at the very least, probably check in on your vitamin D status and check in to see if you're anemic, and looking specifically at a bunch of different iron markers to see like, what's going on you can have you can have anemia for a number of different reasons, not just iron. You can also have iron overload, which is associated with fertility issues as well. So checking in on that, I think, would be key as well.

Well. Thank you so much. This was an extremely insightful, interesting conversation. I have not read your book yet, but I am going to buy it today.

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