Physiology

The Brewer Diet consists of 14 food groups which a mother can choose from daily or weekly.[1] However, the diet can be summarized as having four basic components: 2600 calories, 80-120 grams of protein, salt to taste, and unrestricted weight gain.

The specifics of the diet have been compiled by Dr. Tom Brewer, an obstetrician, after years of studying the research and information available since 1929, on the effects of nutrition in pregnancy.[2] He has been able to see his philosophy used to prevent or treat various complications of pregnancy, including PIH (elevated blood pressure), edema (swelling), pre-eclampsia, eclampsia (toxemia), "gestational diabetes", premature labor, anemias, abruption of the placenta, IUGR (intra-uterine growth retardation), and low birth weight (which can cause babies to be infection-prone). All of these problems have a common source--food deficiency and low blood volume.[3]

One of the main functions of the pregnant body is to preserve the pregnancy and nourish the baby. The body's ability to do this well depends a great deal on its ability to increase the mother's blood volume. Normally, this blood volume is expected to increase by 50-60%, over the course of the pregnancy.[4] For a woman with a pre-pregnant weight of 130 pounds, this would be a increase of about 2.1 quarts of blood (from about 3.5 quarts at the beginning of the pregnancy to about 5.6 quarts at the end of the pregnancy).

The pregnant woman's liver makes albumin to facilitate this blood volume expansion. Albumin is similar to egg white. When it is in the mother's bloodstream, it creates osmotic pressure, which pulls extra fluid out of her tissues and back into the blood circulating in her blood vessels. The only way that the liver can make this albumin is from protein which the mother eats.

However, if the mother is trying to restrict her weight gain to someone's "ideal" number, by going on a high protein, but low calorie diet, much of the protein that she eats will get burned up for calories. Brewer has found that when a woman eats 1/3 less calories than the 2600 calories that he suggests, or about 1700 calories, half of the protein that she eats will get burned for calories.[5] In that case, only 60 of her 120 grams of protein would get used to make albumin (and baby cells, and uterine muscle cells), and she will probably have trouble expanding her blood volume adequately.

Salt also has osmotic pressure which helps to pull extra fluid out of the tissues and into circulation. While salt restriction may be helpful for pregnant women who have unhealthy hearts or kidneys, it is dangerous in healthy women. A healthy woman's taste buds are usually the most accurate indicator of the amount of salt that she needs, and studies have shown that it is not possible for a healthy pregnant woman to eat too much salt. Her kidneys simply excrete whatever extra salt that she eats.[6] In fact, it has also been shown that after just 2 weeks of "salt in moderation", the mother's blood volume begins to drop.

	High Salt Diet	Low-Salt Diet
Toxemia	37/1000	97/1000
Perinatal deaths	27/1000	50/1000
C-section	9/1000	14/1000
Abruptio placenta	17/1000	32/1000

When the blood volume stops increasing, or drops, the body has no way of knowing that the mother is just eating less. All it knows is that the blood volume is less than it's supposed to be. So it starts the same processes that it uses when the blood volume is dropping due to hemorrhage. The internal organs must be preserved, at the expense of the limbs, if necessary. So the kidneys produce an enzyme called renin, which causes the blood vessels to constrict.[7] During hemorrhage, this response is a very helpful stop-gap measure, decreasing the amount of blood in the limbs, to send more blood to the internal organs, while help is on the way. During pregnancy, however, when no hemorrhage is occurring, this blood vessel constriction causes a rise in blood pressure. Attempting to treat this rising blood pressure with salt restriction, or weight restriction, only causes the blood volume to drop even more, leading to further formation of renin and more blood vessel constriction. And the blood pressure continues to rise.

Meanwhile, the kidneys are desperately trying to increase the blood volume by reabsorbing as much water and salt as they can, from the fluid that they have filtered out of the blood. They return this reabsorbed fluid and salt to the circulation. However, since there isn't enough albumin and salt in the circulation to hold this reabsorbed water, much of it leaks out into the tissues. The kidneys keep reabsorbing water at one end of the process, the water keeps leaking out of the capillaries at the other end, and the mother sees rapid swelling in her ankles, and rapid weight gain (from the extra water in her tissues).

The mother presents herself to her birth attendant (doctor or midwife), who tells her that she is developing pre-eclampsia. If her nutrition is not improved quickly, or if diuretics are prescribed (in medications or herb teas), her blood volume will continue to drop, and she will develop eclampsia (toxemia). Toxemia can culminate in convulsions, coma, and death. Many sources maintain that there is no known cause of toxemia, and therefore many practitioners continue to try to manage the situation by treating the symptoms alone, but they do so without success.[8] The symptoms not only persist, but the mother also continues to experience one complication after another.

Some pregnancy teas and some supplements and juices contain nettle, dandelion, alfalfa, bilberry, or celery, which all have diuretic properties and should be diligently avoided.

One way to treat pre-eclampsia is to educate the mother about the cause of her illness, and strongly encourage her to eat according to the Brewer Diet plan, and suggest that she eat something every hour that has protein in it. When the problem seems to need a more immediate response, the birth attendant can give the mother albumin intravenously,[9] and sometimes put her on antibiotics (to lessen the load on the liver by aromatic toxins from the intestines).[10] Dr. Brewer would often tell of one woman who, unable to find a doctor who would give her IV albumin, brought her blood pressure down by eating 52 eggs and drinking 6 quarts of milk, over a period of 3 days.

Anne Frye recommends having the mother eat a high protein item every waking hour. She also suggests, "Initially recommend an increase to 150 to 200 grams of protein daily (250 to 350 grams or more with multiple gestations), with 3,000 to 4,000 calories and 500 mg of choline daily...If the woman has a history of liver disorders, recommend less protein (120-150 grams for a single fetus); her liver may be overwhelmed otherwise, and monitor her lab work closely for changes...Once liver enzymes and blood proteins have normalized, the hemoglobin has dropped appropriately, the fetus is an appropriate size for dates and secondary symptoms have subsided, the woman can cut back to 100 grams of protein daily (150 grams with multiples)."

All of the other complications mentioned earlier are also related to blood volume, and the lack of adequate nutrition, in a similar way. If the malnutrition is not corrected, some liver tissue can die and hemorrhage, leading to small hemorrhages in the mother's adrenals, lungs, brain, and the lining of her heart. The cells lining the capillaries in the kidneys can be damaged as well, and the falling blood volume can cause kidney dysfunction.[11] Abruption of the placenta (when the placenta becomes detached) can happen when the blood volume is so low that the maternal pool of blood that is normally behind the placenta begins to clot.[12] "Gestational diabetes" can result from a decreased carbohydrate tolerance, otherwise known as starvation diabetes, which in turn can be caused by not eating enough carbohydrates.[13] Growth retardation[14] and low birth weight[15] can result from the lack of nutrients in the mother's blood, and from the low pressure of the blood behind the placenta. The baby can suffer neurological impairment, due to this lack of nutrients and calories when his brain is at the most critical stage of its development.

Ninety percent of premature labor is caused by inadequate nutrition and falling blood volume[16] It has also been noted that the blood volume necessary to prevent premature labor increases in proportion to the number of babies the mother is carrying. The exact mechanism is unknown, but there is speculation that it is due to the fact that an undernourished placenta is less capable of producing the muscle-relaxant which keeps the uterus quiet during pregnancy, or that an inadequate blood volume somehow triggers an increase in the production of oxytocin by the pituitary. In any case, premature labor due to an abnormally low blood volume can be prevented with a proper diet, and it can be stopped with the use of IV fluids (without medications added), or IV albumin.

In addition, malnutrition can lead to several labor complications.

1) Inadequate nutrition can mean that a small baby is more difficult to push out than a large one is. When the baby is small because of food deficiency, the uterus is also malnourished and less capable of functioning at its full potential.[17]

2) The pelvis is designed to stretch during labor. An undernourished placenta may produce less of the hormones needed to loosen the pelvic ligaments so that the pelvis can stretch to allow the baby through.

3) With a lower than normal blood volume, the mother is more prone to dehydration.[18] In case of extra bleeding, she doesn't have the fluid reserves to draw from, which she could have been building, had she been on a better diet.[19]

4) In fact, postpartum hemorrhage is more likely with a malnourished mother, since her liver damage can cause her clotting mechanisms to malfunction.[20]

The Brewer Diet is important in all three trimesters of pregnancy.

In the first trimester, the Brewer Diet is important to prevent ketosis (the accumulation of ketones in the blood, from the breakdown of the mother's body fat), and to help prevent or minimize morning sickness, as well as for promoting blood volume expansion and tissue building (making baby cells and uterine muscle cells).

In the second trimester, good nutrition is important for optimal placental development. If the mother has been on the Brewer Diet, and if she doesn't smoke, she doesn't have to worry about the placental function, if the baby happens to become "overdue".[21]

In the third trimester, this diet is important to help build up fluid reserves for labor, and to ensure that the placenta is nourished well enough to keep functioning. It is also important to eat well because the baby's brain goes through its most rapid rate of growth in the last 2 months of the pregnancy.[22] The problem with limiting a mother to a certain number of pounds is that she will often reach that number before the end of her pregnancy, and then starve herself for the rest of her pregnancy.[23]

Some birth attendants discourage mothers from using this diet, with predictions of weight gain that will be difficult to lose after the baby is born. This concern about weight gain often shows an unfamiliarity with the weight loss usually associated with breastfeeding. It can also show that they are neglecting to apply the "risk vs. benefit" test to this nutrition therapy which is commonly applied to other proposed therapies. When this test is applied to the Brewer diet, the benefits of avoiding severe complications with the pregnancy, labor, or baby, easily outweigh the risk of possibly being slightly overweight for a year or two after the baby's birth.

The Brewer philosophy is that the number of pounds gained by the mother during pregnancy is not as relevant as is the kind of food eaten to gain those pounds. The average weight gain on the Brewer Diet seems to be about 35-45 pounds. However, if a woman can show that she is eating well, and that she's not trying to artificially limit herself to a certain number of pounds, a weight loss of 5 pounds might be healthy, and a weight gain of 60 pounds could also be healthy (or more, for a multiple pregnancy).[24] The bottom line is that the first question for a pregnant woman arriving at a prenatal visit should not be, "What have you gained this week?" Rather, the first question for every mother should be, "What have you been eating?"[25]*

Taking Care of Your Nutrition

1) Check your diet

Tape a piece of paper to your refrigerator and write down everything that you eat, for a week. You can then use a chart in a nutrition book to add up how much protein you got every day, and find your average for the week. You can do this every week, or once a month, to see how close you are to your goal. You can also check for calories and other nutrients, at the same time. The Adelle Davis books, available in your local library, or through inter-library loan, have excellent charts, titled "Tables of Food Composition".

Or you could use the Brewer Diet chart, as found in Right from the Start (p. 19), and just check off servings, with no protein counters or math required.

2) Try eating frequent small meals, or hourly snacks such as fruit, nuts, and cheese.

3) When choosing a prenatal class, find out if the Brewer Diet is taught there. The Bradley Method is one of those classes which do teach the Brewer Diet.

4) When choosing a birth attendant, find out if s/he supports the use of the Brewer Diet, and unrestricted weight gain.

There are two central facts which need emphasis:

1. The human placenta creates an ARTERIO-VENOUS SHUNT (A/V) in the maternal circulation. During the last trimester of normal pregnancy, 50 to 60 jets of arterial maternal blood spurt up against the fetal cotyledons with each maternal cardiac systole. This blood swirls about in the intervillous space and passes via "tub drains" back into the uterine venous system.

2. The A/V shunt requires for optimal fetal growth and development an INCREASING MATERNAL BLOOD VOLUME throughout the second trimester to a plateau which must be maintained throughout the entire third trimester.

Failure to recognize these two well-established facts has created havoc in human maternal-fetal health throughout the whole western world, especially in the USA, Canada, and the United Kingdom. The observed reduction in utero-placental blood flow associated with common human reproductive pathology has not been correctly interpreted as the result of hypovolemia, failure to maintain a physiological expansion of maternal blood volume.

Physicians commonly carry out dietary restrictions of calories and sodium and give drugs, diuretics, sodium substitutes, anorexiants, vasodilators etc. which actually cause and/or enhance maternal hypovolemia. Intrauterine fetal growth retardation (IUGR) and small for gestational age (SGA) babies have increased dramatically since the 1950s, especially in these three nations, where the role of prenatal malnutrition in causing human reproductive casualty in still universally denied by medical authorities. Applied physiology and basic nutrition science in human prenatal care as a routine for all women all through gestation much form the basis of true, primary prevention in this field.

Anne Frye, CPM
Portland, Oregon
www.LabrysPress.com
www.AnneFrye.com
www.midwiferybooks.com
503-255-3378
(Pacific time--three hours earlier than EST)
afryemdwf@gmail.com

Anne provided full maternity care for women seeking homebirths for 14 years. When she studied to be a midwife, she was trained to use the Brewer diet as a primary means of optimizing each woman's chance of achieving a healthy pregnancy. In working with a poor immigrant population on the Texas/Mexican border she saw first-hand what a powerful tool diet can be to make this possible. Since that time she stopped actively practicing and focused on teaching as well as authoring professional-level textbooks with an emphasis on preventive care, including the nutritional management of pregnancy. Her textbooks include Understanding Diagnostic Tests in the Childbearing Year, Holistic Midwifery, A Comprehensive Textbook for Midwives in Homebirth Practice, Vol I Care during Pregnancy and Vol II Care of the Mother and Baby during Labor and Birth and Healing Passge: A Midwife's Guide to the Care and Repair of the Tissues Involved in Birth. These texts are available through her website. She also regularly offers consultations to care providers of all kinds as well as mothers who have questions about diet in pregnancy, troubleshooting preeclampsia, nutritional support for multiple gestation, interpretation of laboratory results, as well as other issues. Feel free to call her if you would like to talk to someone who has first-hand experience regarding the value of nutrition in ensuring a healthy pregnancy.

Note from Joy: As you evaluate your nutrition and lifestyle, it would also be helpful to evaluate your level of activity and add extra nutritious calories if you use extra calories during the week, with jogging, biking, skating, skiing, or other sports, or other extra calorie-depleting activities, like teaching, dancing, waitressing, nursing, doctoring, or other activities that keep you on your feet all day. Caring for other children, working both outside and in the home, caring for other family members, and housework would also use up a lot of calories, especially as the baby gets bigger and you burn up calories just carrying around the extra weight of the baby, uterus and extra blood volume. You can also evaluate whether other stresses in your life might be using up extra calories. If you have had extra stresses in your life, then adding extra nutritious calories and other nutrients to compensate for those calorie-burning stresses would help to keep your blood volume expanded and your pregnancy and baby healthy.

The usual eating pattern that we suggest that pregnant women can use to keep up with their nutritional needs is as follows: breakfast, mid-morning snack, lunch, mid-afternoon snack, supper, bedtime snack, middle-of-the-night snack. If you are having trouble keeping up with the amount of food that you need, or if you are having trouble keeping your blood pressure within a normal range, we suggest that you eat something with protein in it (glass of milk, cheese cubes, handful of nuts, handful of trail mix, etc), every hour that you are awake.

Please be aware that traveling and moving can disrupt your eating routine just enough to trigger a low blood volume problem which can start the rising BP/pre-eclampsia/HELLP/premature labor/IUGR/abruption process. Putting the brakes on that process can be more difficult than preventing it. Sometimes just being aware of this danger is enough to help you to remind yourself to continue providing for your nutritional needs, in spite of any changes and stresses which may be going on in your life.

If you are dealing with nausea, vomiting, or diarrhea, it is important to try to alleviate those problems as soon as possible, since they also contribute to depleting your blood volume. You can try frequent, small snacks, herbs, and homeopathy to help you in this effort. If you decide to try using ginger, which can be very effective for "morning" sickness, use it only in small amounts, and only just before eating some kind of food, since too much ginger can cause bleeding and possibly miscarriage.

It would also be helpful for you to evaluate whether you are ever in situations that result in your losing extra sweat and salt--situations such as gardening in hot weather, exercising, living in hot homes during the winter, or living without air-conditioning in the summer, or working in over-heated working conditions. If you do have one of those situations, it would be helpful for you to add extra salt and nutritious fluids to your daily nutrition. This extra effort will help to keep your blood volume expanded to where it needs to be to prevent elevated blood pressure, pre-eclampsia, and other complications.

Eating the recommended amount of protein every day isn't enough to keep your blood volume expanded to where it needs to be for preventing complications in pregnancy. It is also vitally important to make sure that your intake of nutritious calories and salt are also at the recommended levels, with special extra allowances added as needed for your unique situation.

I would also like to add here the assurance that Dr. Brewer is not blaming the mother for her situation. He is clearly blaming her doctor for not having the routine of examining her nutritional status and doing a differential diagnosis for her. He is saying that if her doctor is not doing this with her, then it is most important for her to do it for herself, for the sake of her own health and that of her baby.

The following is reprinted from "Chapter 1" of Eating for Two, by Isaac Cronin and Gail Sforza Brewer, 1983.

"The Complete Pregnancy Diet: Meeting Your Special Needs", by Gail Sforza Brewer (p.1)

Agnes Higgins, past president of the Canadian Dietetic Society and director of the Montreal Diet Dispensary [as of 1983], has developed a procedure for estimating calorie and protein requirements in excess of the pregnancy levels we've already established as a baseline. She emphasizes that any of the following factors increases a mother's nutritional needs:

As a corrective allowance, Mrs. Higgins and her staff counsel mothers to add twenty grams of protein and two hundred calories to their basic daily pregnancy diets for each condition listed above (an individual mother may be experiencing more than one of these stress conditions).

Multiple pregnancy is the only exception: each extra baby requires a nutritional supplement of thirty grams of protein and five hundred calories per day. Higgins comments that this requirement can be met most economically by adding one quart of whole milk a day to the expectant mother's diet (to be drunk, used in cream soups, custards, milkshakes, cream pies and tarts, or as exchanges in yogurt, ice milk, and natural cheeses). Of course, there are many other ways to increase the protein and calories during pregnancy by eating an additional four-ounce serving of meat, fish, shellfish, poultry, or meat substitute as detailed on the diet list. A sample daily menu plan for a mother expecting twins would look something like this:

Generally speaking, these conditions result in an increased appetite; however, women who are working, moving their households, or under emotional stress sometimes fail to pay attention to their bodies' signals for more food. Calling special attention to their extra needs by assigning specific goals for extra protein and calorie consumption makes it much less likely that their nutritional needs will go unfulfilled.

Undernutrition means any protein deficit between what you're used to getting from your food and the minimum adequate pregnancy requirement (eighty to a hundred grams per day). The Higgins nutrition intervention method uses a twenty-four hour diet recall, a technique you can use on your own to see how close your regular diet has been coming to what you actually need. You will need to write down everything you've eaten for the past twenty-four hours (pick a typical day for you), including all snacks, all beverages, and all second helpings. Note what the food was, how much you ate, then consult the Protein-Calorie Counter (see Appendix) to check the amount of protein contained in those portions of those foods. For each gram of protein you lack, add that to your personal protein goal, plus an additional ten calories to free that protein for its most important work in pregnancy: keeping you own tissues healthy and building those of your unborn baby. If you come up with a deficit of ten grams of protein, then, you also need to add a hundred calories to your basic requirements.

Q: Can I get some of the protein I need by drinking protein drinks, instead of working at getting it all from food?

A: It is better to not use protein drinks during pregnancy (referring to drinks which are made from powdered preparations--sometimes used by athletes for building muscle mass). It is better to get your protein from food. One of the homebirth doctors in the Chicago area has noted that when his clients use protein drinks as one of their sources of protein, the babies tend to become bigger than the babies whose mothers get their protein from food.

As a reference point, most of the homebirth midwives and doctors that I'm familiar with in the Chicago area consider birth weights of 7 lbs to 9 1/2 lbs to be average weights for a well-nourished baby. So a baby would have to be over 9 1/2 or 10 lbs to be considered to be on the higher end of normal.

About 10-15 years ago, one Chicago-area practice of homebirth doctors had a client who gave birth to a 15 lb baby at home, with no problems and no perineal tears.

Tom Brewer considered any birth weight below 7 lbs 2 oz to be less than optimal.

So what a birth attendant considers to be "big" for a baby is quite relative. Those who would consider a baby over 8 1/2 pounds to be "too big" have probably had their view influenced by their having seen a predominance of pregnant women who aren't as well nourished as they could have been. However, the homebirth practice that noticed that babies seem to grow bigger when the mothers use protein drinks has been practicing with the philosophy that the Brewer Diet is important in pregnancy, and they would most likely be familiar with the 7 to 9 1/2 pound average birth weight for well-nourished babies. So it is my impression that they were referring to babies being bigger than that average when mothers in their practice used protein drinks.

In answer to the question, "Can protein powders or pills substitute for some of the protein exchanges on this diet?" Gail and Tom wrote the following, in The Brewer Medical Diet for Normal and High-Risk Pregnancy (p. 104).

No. They are extremely expensive sources of protein. They are often incomplete sources of protein (deficient in one or more of the essential amino acids, or containing them all, but in a most unbalanced form). They are often derived from milk, so why not just use the real food--milk? You do not obtain all the other factors found in real food when you pop a pill or pour out a powder. About the only time we have ever recommended these supplements was when a woman expecting quadruplets called us on our hotline. She knew she had a tremendous nutritional challenge to meet, and by the sixth month of pregnancy she had almost no room to put her food. By concentrating protein and calories into the same amount of milk she had been drinking all along, she was able to keep up with her protein requirement.

In September of this year (2008) a study came out from Denmark which seems to emphatically support something which the Brewers and their supporters have been saying for over 30 years. That is that pregnant women who lose extra salt, or burn extra calories, through extra exercise NEED to compensate for those losses by adding extra salt and calories to their diets. When they do not make special allowances for their unique needs in this way, their blood volume will drop, and they will develop rising BPs, pathological edema, pre-eclampsia, HELLP, IUGR, premature labor, underweight babies, and other complications associated with low blood volume. This particular study was looking at only pre-eclampsia, and only at recreational exercise, but those of us who understand the Brewer principles understand that the same principles do apply to all of these other complications, and to any source of salt/fluid/calorie loss, as well.

"Women who exercise during pregnancy face risk of pre-eclampsia, researchers warn"

Complications	Control Group (750)	Nutrition Group (750)
Preeclampsia	59	0
Eclampsia	5	0
Prematures (5 lb. or less)	37	0*
Infant Mortality	54.6/1,000	4/1,000

	Number of Pregnancies	Cases of Convulsive MTLP (Eclampsia)
Tompkins 1941	750	0
Hamlin 1952	5,000	0
Bradley 1974	13,000	0
Davis 1976	500	0
Brewer 1976	7,000	0
Total	26,250	0