Weight Gain in Pregnancy

The following is reprinted from What Every Pregnant Woman Should Know, by Gail Sforza Brewer, with Tom Brewer, M.D., 1977. Please note that the use of diuretics in pregnancy was much more common back then. I believe that Dr. Brewer can be given a lot of the credit for the fact that they are rarely or never used in pregnancy now. The principle that weight control during pregnancy is hazardous to both the mother and the baby still stands, regardless of whether diuretics are used to assist in that control or not.

For a comparison between the Brewer Diet and the ACOG Diet, see here...

"Weight Control: a hazard in pregnancy" (page 15)

The idea that the weight of a pregnant woman should be controlled has been prevalent in obstetrics for a long time. Too long.

As medical knowledge has advanced, particularly about the way the baby develops in utero, it has become clear that the practice of strict weight control benefits neither the mother nor child. The thinking of Amercan obstetricians, however, continues to be conditioned by four theories which have been popular for years:

1. Weight restriction is beneficial to the mother because it makes delivery easier.

2. Weight restriction is beneficial to the mother because it prevents toxemia.

3. Weight restrictioin does not harm the baby because the baby is a parasite, able to take what it needs from the mother.

4. Weight restriction does not harm the baby because the baby's birth weight is determined by heredity.

1. There is no denying that weight restriction results in smaller babies. Nineteenth-century medical school professors from Brunninghausen in 1803 to Prochownick in 1899 wrote extensively on the subject. But the idea that a smaller baby necessarily makes for an easier delivery overlooks a critical corollary to weight control--nutritional deprivation. In circumstances where mothers are on deficient diets, the weight control that results in a smaller baby is now known to also result in a uterus that is likely to malfunction during labor. Labor is often prolonged in these cases. Sometimes it stops altogether and the uterus must be artificially stimulated by drugs into further contractions. When this fails, Caesarean section is the only recourse. Dr. Cecil Mary Drillien reported in 1958 in the Journal of OB/GYN of the British Empire that more maternal complications are associated with low-birth-weight babies than those of normal weight. Among four hundred low-birth-weight infants studied, 52 percent of mothers experienced complications, whereas only 10 percent of the mother of babies with normal birth weight experienced complications. These observations have been confirmed by many other researchers. Advocating weight control during pregnancy as a way of making labor easier simply does not correspond with the facts.

2. The notion that a mother who gains too much weight in pregnancy is more liable to develop toxemia arose because of confusion about what causes the disease. The predominant theory for many years was the "utero-placental ischemia theory." Its proponents believed that fatty accumulations around the blood vessels in the pelvis interfered with the flow of blood to the uterus. The placenta supposedly responds to the reduced blood flow by releasing an as yet unidentified "x" substance. The "x" factor, the theory holds, causes blood vessels throughout the body to constrict, raising the mother's blood pressure to dangerous levels. Direct damage to the mother's kidneys, lver, brain and other vital organs are also blamed on this constriction of blood vessels.

Were this theory correct, the obstetrician would certainly be justified in controlling the weight gain of every patient. Toxemia is one of the most dangerous pregnancy complications. However, evidence from investigators around the world, reported since the 1930's, point to an entirely different cause of toxemia--maternal malnutrition during pregnancy. This metabolic theory traces the onset of toxemia to a lack of nutrients essential in pregnancy, chiefly protein. Lack of these nutrients results in a malfunctioning liver. Various compensatory mechanisms throughout the body are called into action when liver function fails. These mechanisms account for the high blood pressure and abnormal swelling that characterize toxemia.

3. The "parasite theory" supports weight control because it contends that the developing baby takes priority for essential nutrients over the mother's own tissues. If any necessary nutrients are missing from the mother's diet, the baby is able to extract whatever it needs from the mother's body: protein from her muscles, calcium from her bones, etc. In this way, the theory holds, the baby is guaranteed normal physical and mental development in the womb, no matter how malnourished the mother may be. If the baby is small at birth, no one is to worry. These theorists see the small baby as merely perfection in miniature.

4. Enter the "genetic theory" which maintains that the baby's weight and length at birth are inherited traits. If the parents are tall, the baby will be big; if short, small. This theory has been used as a way of explaining the much higher incidence of low birth weight and brain-damaged children among lower income groups in our country. Epilepsy, for instance, is ten times more common among the poor. If these problems can be traced to genetic inferiority, then there is nothing anyone in authority can do except perhaps build more institutions to care for the retarded. If everything about a baby's development is predetermined by the parents' legacy of chromosomes, there is little that can be done to improve the outcome of pregnancy short of choosing the right ancestors, as one well-known obstetrician has only half-jokingly suggested.

If either the parasite theory or the genetic theory were valid, neither restricting nor supplementing the diets of pregnant women should have any effect on their babies' birth weights. Yet it has been known since the nineteenth century that weight control results in a smaller baby, and Mrs. Agnes Higgins of the Montreal Diet Dispensary has shown over the past twenty years that improving a mother's diet results in a larger newborn.

The four theories discussed above have influenced the training of most obstetricians in practice today, so that weight control remains a fixture in American obstetrics. Doctors continue to seek a definitive answer to an irrelevant question: How much weight can a pregnant woman gain without placing herself or her baby in jeopardy?

The current "magic number" is 24 pounds, accounted for by a prominent obstetrician in this way:

Fetal tissues (baby).......................7 1/2
Placenta.......................................1
Amniotic fluid................................2
Organ growth.................................2
Growth of breasts..........................1 1/2
Increase in blood...........................3 1/2
Tissue fluid and stored body fat......6 1/2
Total maternal weight gain:............24 pounds

This table appears to be based on a scientific analysis of the various physiologic changes that occur in normal pregnancy. However, recearch demonstrates that when weight control is not practiced and the mother is encouraged to maintain throughout pregnancy optimal nutrition, including adquate salt intake, she commonly gains ten pounds more than this table indicates. Additional circulating blood, tissue fluid and stored fat comprise these ten pounds. This is not excessive, undesirable weight. Rather, as we shall see, this increase is a proven safeguard for mother and baby that is subverted when weight control is practiced in lieu of scientific nutritional counseling.

A booklet published in 1974 by the American College of Obstetricians and Gynecologists contains a chart which indicates that the twenty-four pounds must be gained according to a set pattern in order to minimize obstetrical risks. Deviations from this pattern are to be interpreted as warning signs. A statement accompanying the chart also explains that twenty-four pounds are not to be gained by every pregnant woman. Those who are overweight at the time of conception should have a smaller weight gain because by the end of the pregnancy a mother should weigh no more than twenty-four pounds over her "ideal weight" for her height. The determination of appropriate weight gain in any individual case is left to the discretion of the physician.

This chart first appeared in a medical journal, Clinical Obstetrics, in 1953. Since its publication many comprehensive clinical studies have been reported in major journals here and abroad. In fact, some of these studies originally were published in ACOG's own journal. Evidence from these more recent investigations leads to the conclusion that for numerous reasons it is hazardous to rely on weight control as a tool for management of human pregnancy. To the contrary, healthier mothers and babies result with the focus is on nutrition, not pounds.

Hytten and Thomson, British investigators writing on maternal physiologic adjustments in pregnancy in a 1970 publication of the National Academy of Science, were struck not by the supposed predictability of weight gain in normal pregnancy, but by its variability. They present convincing evidence that normal pregnancies can take place within a wide range of weight gain and loss, and that the pattern of weight adjustment is a function of individual metabolism and activity. It is, therefore, not wise to attempt to regulate it.

They note that it was hard to find subjects for their research since many--perhaps most--obstetricians advise patients to eat less than their appetites dictate, thus altering the normal adjustments they wanted to study.

The 746 Scottish women chosen for investigation met all the criteria for normality in pregnancy: they were between the ages of twenty to twenty-nine, at least sixty-three inches tall, in good physical condition and were allowed to eat to appetite. All gave birth to normal, healthy babies between the thirty-ninth and the forty-first week of gestation.

A chart showing the distribution of their weight gains over the last twenty weeks of pregnancy disproves every point advanced in the ACOG weight-control chart. Instead of each mother gaining the same amount of weight per week in the last twenty weeks, some mothers gained virtually nothing while others gained overy forty pounds! Neither the total number of pounds gained, nor the pattern in which it was gained had any effect on the outcome of pregnancy. All mothers and all babies were normal.

Clearly some factor other than the number of pounds gained was responsible for the normal outcomes of these pregnancies. A look at what the mothers were eating, a variable the study failed to detail, would be more productive in terms of providing practical advice for the physician to pass along to his patients.

Of course, if one looks at all the pregnancies in this study and averages the weight gains an absolute number is reached. However, this statistical approach to the question of what is the correct management of an individual pregnant woman can only lead to difficulties. To establish the average of all weight gains in normal pregnancies as some sort of "ideal" to which every individual case must correspond means that only those mothers for whom the "ideal" is physiologically compatible will be managed properly. All others will be coerced into following a pattern which does not foster their most healthful adjustment to pregnancy! In short, they are placed at higher risk of developing complications.

Babies are also more likely to suffer when the obstetrician's attention is devoted to controlling the mother's weight. Low birth weight commonly results when the mother follows advice to restrict calories and salt and to take diuretics during pregnancy. As was pointed out in 1968 by the National Institutes of Health Collaborative Study of Cerebral Palsy, "Mental Retardation and Other Neurological and Sensory Disorders of Infancy and Childhood," the baby who weighs under five and a half pounds at birth is more apt to be afflicted with such defects as mental retardation, cerebral palsy, epilepsy, hyperactivity, learning disabilities, respiratory distress syndrome (RDS) and sudden infant death syndrome (SIDS).

Most doctors know that in the last two months of pregnancy the baby who is developing normally experiences an unparalleled growth spurt. Many seem not to realize that this critical phase of the baby's development can be seriously disrupted by inadequate maternal nutrition during these last few weeks of gestation. When the physician rigidly enforces a weight gain limit, mothers often reach it just as the baby's growth spurt begins. When a mother starts to cut down on her food and salt intake in order not to exceed her doctor's weight limit, she unknowingly begins to starve her unborn baby. It is tragic that as she earnestly strives to carry out her doctor's orders in the belief she is doing the best for herself and her baby, the mother is actually placing them both in jeopardy.

The work of Dr. John Dobbing--a research professor in the Department of Child Health. University of Manchester Medical School, England--explains how interference with maternal nutrition at the end of pregnancy compromises the growth of the baby's brain in particular. In February of 1976, he concluded in a talk at the Montreal Childrens' Hospital:

Even mild degrees of maternal undernutrition in the last few weeks of pregnancy can interfere with the normal growth and development of the human fetal brain.

For many years Dobbing has studied how the brain of the unborn baby develops. Identifying two periods of rapid growth of brain cells--the first at twenty weeks gestation and the second at thirty-six weeks, one month before the baby is born--he believes that the developing brain is most vulnerable to the effects of maternal malnutrition at these times.

Since even "mild degrees of maternal undernutrition" can interfere with the baby's brain growth and development, the doctor must recognize what constitutes such "undernutrition," so it can be prevented in every pregnancy.

A sample day's menu from a typical low-salt, low-calorie diet sheet clearly exemplifies the undernutrition Dobbing warned against. Though apparently supplying an amount of high quality protein adequate for pregnancy (approximately 90 grams) its severe restriction of calories and salt makes it a hazard to mother and baby.

The importance of adequate protein intake during pregnancy was proven by the pioneering work of Bertha S. Burke of Harvard. In the 1940's she found that women whose diets contained 45 grams or less of protein a day suffered the highest incidence of stillbirths, neonatal deaths, congenital defects, premature and low-birth-weight babies.

The late Professor Benjamin S. Platt demonstrated at the London School of Tropical Medicine that these disorders could be produced experimentally in animals by limiting protein. One way to do this is by restricting protein directly by not allowing the animals to eat protein-rich foods. Another way is to limit the amount of carbohydrates the animals consume. He found that when the calorie intake provided by fats, sugars and starches is reduced below the body's requirements, dietary protein is burned for energy. During pregnancy this means that only the "leftover" protein will be available for growth of the baby and maintenance of maternal health.

A moderately active woman needs approximately 2,600 calories every day to meet her normal energy requirements in the last three months of pregnancy. If she is carrying twins, the figure is closer to 3,100 calories. On the kind of diet recommended for weight control by most obstetricians, she is only going to get 1,700 calories--a deficit of at least 900.

Platt calculated that a deficit of one-third in needed calories results in one-half the dietary protein being burned for energy. So, over half the 90 grams of protein the mother is allowed daily on this diet will not be available for building her baby's body and brain.

In other words, the effect of a "low-calorie, low-salt" diet is to put the mother on a "low-protein" diet--less than 45 grams a day--and right into the severely malnourished group Burke identified in the 1940's as being at higher risk.

The undernutrition caused by protein-calorie deficiency is aggravated by drastic restriction of salt to less then two grams a day. When the mother follows this diet, she and her baby are in trouble.

What Every Pregnant Woman Should Know available here

	Medical research during the last 40 years [as of 1978] has clearly shown that the following pregnancy complications can be directly caused by malnutrition. A. For Mothers: Metabolic toxemia of late pregnancy (MTLP) Preterm separation of the placenta (afterbirth) Severe infections Severe anemias Miscarriages and molar pregnancy Premature labor and delivery Prolonged and difficult labor B. For Babies: Stillborn babies, especially when MTLP and premature separation of the placenta occur Lowered birth weight Prematurity Severe infections Hypoglycemia Birth defects, especially defects of the brain leading to cerebral palsy, epilepsy, mental retardation, hyperactivity, and learning disabilities

Nutritional Deficiency in Pregnancy

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

The following is reprinted from The Brewer Medical Diet for Normal and High-Risk Pregnancy, by Gail Sforza Brewer, with Tom Brewer, M.D., 1983.

Three thousand calories! That's almost twice my usual. Why does pregnancy require so much more? (p. 38)

The main reason is to provide plenty of fuel for your body's daily work so that you won't start using up the protein you eat to do the same thing. If you don't have enough calories, your body automatically burns some protein to make up the difference. When this happens, that protein cannot be used for the job that it alone can do--growth and maintenance of body tissues (i.e., growing your baby's body and brain and supporting all your own body systems in tiptop form). So you slide into a protein deficit, even though it seems that you are getting plenty from your diet when you just calculate protein grams.

This has been a long-standing problem for women because for years a high-protein, reduced-calorie diet was in vogue for pregnancy. This happened because doctors thought that by controlling weight gain they could prevent toxemia of pregnancy. We examine this issue in detail later on, but suffice it to say that the emphasis on weight control became fixed in obstetrics long before nutrition science worked out the intimate relationship between protein and calories. And it's taking a long time for the nutrition educators to get the message across to doctors who were trained to preach weight control to all their pregnant patients.

Confusion about the role of calories in pregnancy is still the number-one concern on our list of hotline calls. The typical situation involves a mother who's been told to eat 90-100 grams of protein a day, but only 1,800 calories, a standard diet that many midwives and doctors give to mothers at their first prenatal visit. It appears to be an excellent diet, as far as protein level is concerned. But if, for example, the mother's energy needs are for 2,600 calories, she turns up 800 short. And more research is endorsing the 2,600-3,000-calorie range for the best obstetrical outcomes now that strict weight control regimens have been linked to low-birth-weight babies and higher rates of toxemia and stillbirth. Should she happen to be working full time or carrying on a very vigorous sports program (or looking after three or four other children), her calorie needs might be upped by a thousand per day. Seldom has the mother's individual activity pattern been evaluated, we find. She has just been handed a printed sheet or a small booklet and told to follow what it says. End of discussion. She calls us when she starts feeling tired or weak or her blood pressure goes up.

Here's what nutritionists know about protein and calorie interaction: If you are not obese and your calories are one-third less than what you need (roughly the situation of our caller), then half the protein you eat is going to be burned for energy! So your 90 grams of protein are whittled down to 45--far below the 75 grams that Burke and others have identified as the bare minimum for a nutritionally secure pregnancy. This is serious business because this is serious malnutrition--disguised as a sound diet.

There is another consideration. It's virtually impossible to obtain all the other essential nutrients you need in pregnancy on such a calorie-restricted program. Iron, zinc, folic acid, vitamin E, and many others are undersupplied. This probably explains how doctors began the practice of prescribing pills to provide these nutrients. The diets that they were using just weren't complete. Advances in our understanding of pregnancy nutrition keep escalating the numbers in the vitamin and mineral columns, so calorie intake must also increase from the additional foods you eat to meet the additional nutrient requirements. Furthermore, every day nutritionists begin research into other factors essential to human nutrition, such as enzymes, which aren't to be found in any pill. They only come in food, another reason we prefer eating nutritious meals to swallowing a handful of pills every day.

The calories you obtain from your food are protective. Eat the nutritious foods on the diet to appetite and you will satisfy the basic pregnancy requirements. Keep in mind, though, that you may need more because of a variety of stress situations that we discuss subsequently.

Do overweight women need all those calories, too? (p. 40)

Maybe not, but they certainly need all the other essential nutrients on the charts--all the protein, vitamins, minerals, fiber, and water. We give overweight women the same advice we give to women of average weight for their height. Eat to appetite nutritious foods from the diet list.

Most often, people become overweight by eating the wrong foods, those that provide lots of calories but not much else in the way of nutrients. You know the kind we mean--candy, cake, pies, cookies, commercial snack foods, sugared soft drinks and imitation fruit punches, alcoholic beverages, fruits packed in heavy syrups, and all the sweeteners: sugar, honey, molasses, corn syrup, maple syrup. These fill you up, but don't contribute much besides calories to your pool of necessary nutrients. An occasional candy bar isn't going to make you fat, nor is it going to harm you or your baby during pregnancy. What does cause problems is the habitual use of these products, to the point where they being to squeeze other foods from your diet because they satisfy your appetite.

When the woman who is truly overweight at the beginning of pregnancy (say, more than 20 percent over her best weight) goes on this diet, she may actually be getting fewer calories than she was eating before, although the amount of food has increased. That's because this diet is high in fresh fruits and vegetables and whole grains, all of which take up more room in the stomach for far fewer calories than a high-sugar diet does. So her nutritional status is improved dramatically by all measures, and she may lose a few pounds or stay about the same over the course of pregnancy--without ever being hounded about pounds or placed on a strict calorie-watching program.

The focus here is on ensuring that the overweight mother corrects her nutritional problems. Her weight problem usually follows suit. Over the course of pregnancy she can use up some of her stored calories (that is, fat), and she and her baby will be perfectly healthy as long as all her protein, vitamin, mineral, and other nutritional needs are met by her diet. Exercise helps, too.

Agnes Higgins, the pioneering director of the Montreal Diet Dispensary and a luminary in the field of pregnancy nutrition, always comments in her lectures that she loves to see a plump woman come into clinic. It means she won't have to worry about calorie deficiency, the way you must when you are working with a thin, underweight woman who has no calorie reserves at the start of pregnancy.

These are the basic principles of nutrition education for overweight mothers. (See Chapter 6 for an expanded discussion.) Obviously, we don't automatically look on every overweight mother as high risk, though many medical people do. In our experience, an overweight mother whose nutritional problems are dealt with positively can be removed from the high-risk category.

Doesn't the advice "Eat to appetite" give women the license to eat anything they want--and gain lots of extra weight they'll never be able to get rid of once pregnancy is over? (p. 41)

Absolutely not. We don't just say "Eat to appetite." We say "Eat to appetite nutritious foods from the diet list." That's quite a different message! We are not in favor of obesity, during pregnancy or at any other time; however, neither are we in favor of diets that restrict essential nutrients--particularly in pregnancy. Your appetite for food, by the way, is not unlimited, no matter what you hear. You "appestat" is a regulating mechanism that controls, with remarkable consistency, how much food you desire. This is a normal feature of the adult human body that enables us to maintian weight to within a few pounds one way or the other most of the time. Granted, some people have cravings for food that exceed all normal bounds, and there are many others for whom eating on and off throughout the day has become a habit. These are disturbances in normal appetite that may reflect other kinds of problems--anxiety, depression, grief, boredom--that need to be resolved. Some people get into the constant-eating syndrome as the result of breaking the cigarette habit. But by far the vast majority of adults arrive at a weight they can maintain, at which they feel the most energetic and stay the most helathy, without continuously monitoring every calorie they consume. Their appetite is the regulator.

It also works the other way: Your appetite usually picks up when you spend a few days at hard physical work (just think of the traditional lumberjack of folk tales). This prevents you from losing excessive weight. During pregnancy you may have a ravenous appetite, even if you have never been a big eater, just because you have so many more metabolic demands than ever before. This is especially true for women who begin pregnancy underweight--they may gain 20 pounds in the first four or five months, which only brings them to what they should have weighed to start with. They may then go on to gain another 20 to 40 pounds--the range that most women fall into for a pregnancy gain. They, too, have been eating nutritious foods from the diet list to appetite: the same advice we've given to women of average and extra weight.

Then there's no set number of pounds that's healthy to gain in pregnancy? (p. 42)

Right. And this is one of the hardest ideas to grasp, since women and their doctors as well have been conditioned to accept the scale as the infallible arbiter of how well their pregnancies are going. The numbers on the scale do not differentiate the kind of weight gain (or loss). Nobody can tell, just from weighing you, whether the 6 pounds you gained this past month represents additional fat, muscle, water, or baby--or a combination thereof. In Norway, you can go for a series of twelve prenatal visits and never once be weighed! And, except fo identifying the mother who is thin and failing to gain, we find it hard to justify the dreaded weigh-in at every prenatal visit. All it contributes to most prenatal visits is anxiety on the part of both mother and health workers.

The number of pounds shown on the scale is absolutely irrelevant to the outcome of pregnancy. What does matter is the adequacy of the mother's nutrition. What she needs to be asked about, in detail, at each visit is whether she's having any problems following the diet and whether she's facing any additional demands that might make the basic diet inadequate for her own life situation. Far better to have every woman bring in her own food record sheets (kept a couple of days each week, as a sample) and have them looked over by the midwife or doctor than to spend five minutes in a harangue over what the scale shows. Keeping a careful watch on the nutritional components of the diet is the key to successful pregnancy, not trying to force everyone into some statistical average of pounds gained.

All the well-done research supports our clinical observations and patient records on this, by the way. In the most comprehensive of such studies, and one of the few in which the nutrition of the pregnant women in the study was actually accounted for, the distribution of weight adjustment over the last half of pregnancy followed the pattern shown in the chart on page 44.

In this study all the mothers were normal, all the pregnancies were uncomplicated, the deliveries went well (no Caesareans), the babies were healthy, and the postpartum course for all mothers and babies was smooth. All of the mothers had been advised what a good pregnancy diet was, none was restricted in any way, they were encouraged to salt their foods to taste, and no diuretics or amphetamines or other appetite-control drugs were used. The goal of the study was to find out what a completely normal woman could expect to gain over the course of a well-nourished pregnancy. The researchers, who had hoped to present a scientifically determined number that could then be used as a standard for all pregnancies, were sorely disappointed when this bell-shaped curve emerged from the computer!

Though all mothers, babies, pregnancies, labors, and postpartum courses had gone well, there was an enormous range of weight lost and gained over the last twenty weeks of the pregnancies studied. On the left side of the chart, a very small percentage of the mothers (2 percent) lost an average of a quarter-pound each week over the last twenty weeks of pregnancy--for a total loss of 5 pounds.

In the center of the chart, the mean weight gain (attained by 25 percent of the women) averaged a pound per week each week over the last half of the pregnancy--for a gain of 20 pounds in the last twenty weeks. This, incidentally, is 2 pounds more than many obstetricians have held on to for years (the old 2-pounds-a-month rule) for the entire pregnancy.

On the right side of the chart, another 2 percent of the mothers gained, on the average, 2 pounds a week in the last twenty weeks--a total gain of 40 pounds, presumably added to whatever the mothers had put on in the first half (perhaps another 10 to 20 pounds). And none of them got sick, had premature babies, or any other pregnancy problems--because they were on adequate diets. Their pounds were healthy pounds, gained on sound diets composed of nutritious foods.

Suppose there are 25 pounds left over after the baby's born? What then? (p. 45)

Give yourself a reasonable time to take the weight off. After all, it took nine months for it to accumulate. Six months (not six weeks) after your baby is born is a far more realistic time frame for returning to your prepregnancy weight. [Webmaster note: Many childbirth educators and midwives use the adage, "Nine months on, nine months off"] When you are breastfeeding, you still have to provide all your baby's nutrients from the foods you eat, so your appetite is likely to continue in high gear until your baby starts taking nourishment other than breast milk as part of his or her diet. Usually by the time your baby is six months old, you will be able to undertake a safe reducing program if you need one. But if you get regular postpartum exercise, your weight should gradually taper down to what it was before you became pregnant. Details of nutrition for you and your baby during the postpartum period are covered in Chapter 6.

The bottom line has to do with your baby's health and development, not just as a newborn, but for life. If you have to choose (and you really don't have to) either having a few extra pounds for a few months and a normal baby or getting right back into designer jeans and a lifetime of caring for a retarded or developmentally handicapped baby, it seems to us that the choice is obvious. The problem for most women is that nobody ever told them that their diets really made that much difference, so the near obsession to avoid becoming overweight has been the top concern of every one, medical professionals included.

The Brewer Medical Diet for Normal and High-Risk Pregnancy available here

The following is reprinted from Metabolic Toxemia of Late Pregnancy, by Thomas H. Brewer, M.D., 1966 and 1982.

Note from Joy: While the use of amphetamines and diuretics may no longer be considered the mainstream treatment of choice for the symptoms of toxemia, other methods of weight control in pregnancy and treatments for toxemia are currently in vogue which are equally hazardous to both the baby and the mother. And unfortunately, the hazards of these current treatments are no more recognized by the mainstream practitioners of today than were the hazards of the earlier use of amphetamines and diuretics by the practitioners of yesterday. I have been witness to some of the current hazardous treatments, just within the past 5-10 years.

I worked for a homebirth midwifery practice for several years. For most of that time, all the midwives were supportive of the use of the Brewer Diet by the clients of the practice. The last year of my time there, we got a new midwife on staff who was very opposed to the use of the Brewer Diet. Whenever we got a new client who was the least little bit on the plump side, she would apparently tell her to get a little more exercise and eat a little less carbohydrates. When her blood pressure would start to creep up, she would tell her to cut back on her salt a little bit. No amount of my trying to explain the Brewer insights to her made any headway. As a result, within the first six months of her being on staff, we had 2-3 clients who had to be hospitalized with blood pressure problems and premature labor, as I recall, which was very uncharacteristic of our practice.

So it is very important that we not dismiss the historical accounts that Brewer has documented for us. We need not look down our noses at his reports of the starvation-amphetamine-diuretic practices of the physicians around him in his early days, and his efforts to stop those practices. We have our own faulty treatments in our own time, which are based on the same faulty thinking, and are just as hazardous as the treatments that he witnessed.

In addition, unfortunately, some areas of the "alternative medicine" community have apparently followed mainstream medicine in the belief that diuretics are important and useful for treating edema and elevated blood pressure in pregnancy. Many pregnancy teas and some supplements and juices include nettle, dandelion, alfalfa, bilberry, or celery, all of which have diuretic properties. Diuretics are no safer for pregnancy in herbal form than they are in prescription medications, so it is important for pregnant women to watch which herbs they are taking.

See here for more information on the hazards of using herbal diuretics in pregnancy

"Weight Gain" (page 71)

Nowhere in medicine are statistics more abused than in modern obstetrics. The information learned from studying a thousand cases from hospital records can not replace a detailed clinical study of the individual patient. False conclusions drawn from many statistical studies about weight gain in pregnancy have clouded understanding and rational practice for many years.

It is clear that a sudden rapid weight gain may be one of the first manifestations of toxemia of late pregnancy. However, we often see severe toxemia in women who failed to gain enough. Among indigent women in the southern states, failure to gain ten pounds or more during pregnancy is an indication of poor nutrition and a significant number of women in this group develop MTLP. We have also observed women who gained forty or fifty pounds during pregnancy and had normal prenatal courses and produced healthy infants. These observations seem confusing until one grasps the basic concept that an obese woman may be "well nourished."

There are thus two distinct categories for excessive weight gain;

1. Excess tissue deposits, chiefly of fat but some protein is stored; and
2. Excess fluid retention.

Both mechanisms may operate in the same woman. Women in the first category may be quite adequately nourished or very poorly nourished depending on their individual experiences. Again we see the importance of taking a thorough clinical history in order to understand the individual patient.

The misplaced emphasis placed on "weight gain" by many modern obstetricians leads to some undesirable consequences. Many women have told me that their physician made such a fuss over their weight gain that they were afraid to go in for the prenatal visit. Women often starve themselves for several days prior to the prenatal appointment, particularly if they have gained excessively. Many women take castor oil or some other strong cathartic the day before the prenatal visit. Women become so preoccupied with keeping their weight down that they fail to place proper emphasis on the principles of good nutrition. Many women with common sense continue to eat a good diet in the face of their physician's criticisms and disapproval, and this leads to a certain discord and disrupts the patient-physician relationship which is important in the psychological preparation of the patient for labor and delivery. All these vexing situations can be eliminated when physician and patient grasp the basic ideas presented here.

Metabolic Toxemia of Late Pregnancy available here

The following is reprinted from the "Afterword to this Edition by the Author" of Metabolic Toxemia of Late Pregnancy, by Thomas H. Brewer, M.D., 1982.

"Weight Gain in Pregnancy" (page 150)

Many studies in the last fifteen years have confirmed my position that weight limitation to any "magic numbers" or "pattern of gain" has no scientific basis whatsoever and is in fact harmful to large numbers of pregnant women. (See Annotated Bibliography, Appendix) If her doctor recommends any arbitrary number as an "upper limit" or ceiling, when the pregnant patient approaches this number or reaches it, she is classically warned to "cut down" on her intakes of foods and salt. This advice to starve usually comes during the last half of gestation when the nutritional needs of the pregnant woman are increasing daily in the quantitative sense. Thus raising the number of the ceiling begs the question and in no way solves the universal problem of iatrogenic [doctor-caused] starvation in human prenatal care.

Women with twins gain more weight earlier in gestation than women with a single fetus when they eat to appetite and salt to taste. The total weight gained in a pregnancy with multiple fetuses is more with adequate diets. When the diagnosis of twins is not made prenatally (perhaps in 40% of cases in the USA), blind weight limitation can be disastrous to both mother and babies. MTLP, low birth weight and prematurity have long been associated with twin pregnancy,a nd the nutritional etiology of this reproductive pathology is now clear. Following the empirical observations of Mrs. Agnes Higgins in the Montreal Diet Dispensary, I advised mothers-to-be with twins to add 30 grams of high quality protein and 500 calories to their diets for each extra fetus; these amounts of protein and calories are present in one quart of milk.

It has been demonstrated beyond all scientific doubt that normal pregnancy for both mother and baby can occur over a wide range of total weight gain and with many different patterns of gain among adequately nourished women. The late Professor Nicholson J. Eastman of Johns Hopkins University, Dept. of Obstetrics, on June 3, 1968, told a small group of physicians at the NIH in Bethesda, Maryland:

"I taught the wrong ideas about weight gain in pregnancy all my professional life."

He made this statement after presenting some of the preliminary data from the NIH Collaborative Study of Cerebral Palsy and from his own studies of weight gain in pregnancy at Johns Hopkins. (Eastmans, N.J. et al Obstet: Gynecol. Surv. 23:1003, 1968).

See here to better understand the evolution of the mainstream medical perspective on nutrition and salt in pregnancy

The following is from a chapter reprinted by permission from 21st Century Obstetrics Now! (David Stewart, PhD, and Lee Stewart, CCE, Editors), National Association of Parents & Professionals for Safe Alternatives in Childbirth, 1977. (p. 387)

"Why Women Must Meet the Nutritional Stress of Pregnancy" (p. 387)

Another area of obstetrics which is completely misunderstood involves weight gain during pregnancy. As in the case with distorted views on salt metabolism, the use of weight control has led to an innumerable number of instances of preventable iatrogenic maternal and infant morbidity and mortality.

Weight gain has been shown to be the maternal factor which is most highly correlated with birth weight.[51] Although weight gain during pregnancy can reflect nutritional status, it is not an accurate indicator of dietary adequacy. One reason that a dietary history and/or blood constituents analysis are more accurate means of assessing nutritional status is that, as in the nonpregnant state, a high weight gain can result from a high-calorie diet which is low in essential nutrients. Also, paradoxically, undernourished (particularly protein-deficient women) can gain a rapid amount of weight in a relatively short period of time as a result of pathological edema. As has been established herein, the edema in such women is a direct consequence of lowered colloid osmotic pressure of the plasma protein caused by hypovolemia [36,102] and frequently leads to metabolic toxemia of late pregnancy.[36]

Since healthy, full-term children are born to women who have a normal pregnancy at a wide range of weight gain (or weight loss), subjecting a group of women to any particular weight control regimen is unscientific and potentially hazardous.[130] Hytten discovered that the distribution of weight gain during the last 20 weeks of healthy pregnancies approaches the normal statistical distribution with a mean weekly gain of one pound.[100] Because of individual differences, it is best for pregnant women to eat a diet of nourishing foods to appetite without regard for their weight gain.[36]

In a study of approximately 8,000 single live births of 37 to 44 weeks' gestation, Lowe demonstrated the direct and highly significant relationship between weight gain and birth weight.[35] The correlation between birth weight and maternal weight gain was 0.94. He showed that the relationship was not continuous, since, at and above approximately 3500 grams (7 pounds 11 ounces), birth weight does not increase as weight gain increases.

Utilizing data from the Collaborative Perinatal study, Singer et al. analyzed the association between weight gain and infant development.[131] They confirmed the findings of other researchers that age, parity, and many other factors are not related to birth weight when weight gain is one of the independent variables. The data in Table 39 show that the incidence of low birth weight is related to weight gain at the .001 significance level.

TABLE 39
CORRELATION BETWEEN
WEIGHT GAIN DURING PREGNANCY
AND INCIDENCE OF LOW BIRTH WEIGHT

	Weight Gain (Pounds) % Low Birth Weight Loss 17.0 0-15 15.8 16-25 8.2 26-35 4.3 36 or more 3.0

They also discovered the relationship between maternal weight gain and infant size and neurological function at one year of age and that between weight gain and psychiatric, mental and motor function at one year of age and that between weight gain and phychiatric, mental, and motor function at eight months of age. Table 40 lists infant size and the three exams in descending order of their degree of association with weight gain. All infant abnormalities except those measured by the neurological exam are significantly related to birth weight on a statistical basis. Even when the relationship between birth weight and infant abnormalities was removed from the analysis, low maternal weight gain was found to be associated with infant abnormalities.

TABLE 40
INCIDENCE OF ABNORMAL GROWTH BY WEIGHT GAIN

	0-15 Pounds (%)	16-25 Pounds (%)	26-35 Pounds (%)	Over 36 Pounds (%)
Weight	15.8	11.2	8.4	6.2
Motor Exam	11.3	8.0	6.8	5.2
Mental Exam	12.5	9.3	8.3	7.5
Height	10.1	7.5	6.5	7.3
Neurologic Test	8.8	7.5	7.9	7.1

Despite the overwhelming evidence of the potentially pernicious consequences of weight control, which is most devastating during late pregnancy (at which time fetal brain development is most rapid), obstetricians still unduly restrict weight on a routine basis. One survey showed that 95% of obstetricians restrict weight gain during pregnancy.[125] A present study showed similar results.[132] A large number of the women were reprimanded for approaching or exceeding their weight quota. One woman, who had gained 23 pounds by the ninth month of pregnancy, said: "He (the doctor) yells at me every visit. He says I eat too much. I just get so depressed. He told me my delivery is going to be harder because of my weight gain."[132]

Despite the accepted practices of weight control and salt restriction, there are, fortunately, physicians who do practice preventive obstetrical care. One physician enumerated the benefits from his emphasis on protective prenatal nutrition:

Letter from a Physician With a Nutrition Program

	When I initially counsel patients with their first pregnancy visit, nutrition is strongly stressed. I do not mention limiting weight in any way but instead tell to gain at least 25 to 30 pounds during this pregnancy and that this weight gain will be a protein weight gain. I give them a list of protein-containing foods and reassure them that much of this weight is to gained in the first few months of pregnancy. I do not at any time, with any visit, tell the patients that they are gaining too much but instead stress only good nutrition ... The patients did need constant support from me since attitudes of others around them tended to express that they were gaining too much weight or that somehow weight gain was harmful in pregnancy. I do not use diuretics in pregnancy, nor any other medications other than a good prenatal vitamin. During the time I have been in practice here, I have managed approximately 500 obstetrical patients, I have had two patients with preeclampsia, both of whom had severe chronic diseases. One of these had systemic lupus erythematosis, the second a hereditary cholesterol problem. Both of these now have healthy babies. I have had six spontaneous premature infants. One of these was from a mother who had acute appendicitis in her sixth month of pregnancy. Three of the patients did not start prenatal care until their sixth month of pregnancy and were severely malnourished when I started with them; two of the patients had placenta previa, and one patient was a total vegetarian whom I judged was on inadequate sources of vegetable protein. The remainder of my patients have had normal, healthy children. One patient had a sudden infant death occur at four months of age. The mother of this baby was an epileptic requiring large doses of Dilantin to control her seizures, and this had been taken all through her pregnancy. Nearly all of my patients breast-feed their babies, and good nutrition is stressed throughout the breast-feeding time. Most of them breast-feed for six months or more. The mothers begin their first breast-feeding on the delivery table and continue to breast-feed every two to four hours throughout the hospital stay. The hospital stay in my patient group averages 24 hours. Cesarean sections taken as a group are kept for approximately 48 hours ... All cesarean section mothers nurse their babies. In answer to the question "Do doctors in our area limit weight gain?" I would say most still do ... As an aside, there are a number of other phenomena which we accepted as "normal in pregnancy" which I have realized were nutrition-related and which I do not see in my practice any more ... Mothers who are properly nourished do not get stretch marks, and they do not seem to have acceleration of dental caries or softening of the gums. I do not see loss of hair, splitting of nails, softening of bones, anemia, postpartum hemorrhage, or failures at nursing. In addition, after the fourth month of the pregnancy, most mothers feel normal as far as energy output. We see very quick recoveries after pregnancy, and we do not see failures at breast-feeding because of nutritional problems in the mother.[126]

Why are so few obstetricians attuned to the role of maternal nutrition in protecting the health of the expectant mother and her unborn? A professor of OB/GYN reflected:

Because obstetricians are not educated in the field of practical nutrition, they are susceptible to unscientific advertising claims of the drug industry. As late as 1974, diuretics and appetite suppressants were advertised in major obstetrics journals.[134] In addition, the medical profession, especially the American College of Obstetricians and Gynecologists (ACOG), have directly or indirectly sanctioned the use of medical regimens which lead to reproductive pathology. The powerful American College did not form a Committee on Nutrition until 1972. Their first position paper on maternal nutrition, which is replete with myths and unscientific speculation, was not published until December 1972.[134] A recent enumeration [as of 1977] of the ACOG's ten-year goals did not include mention of the implementation of nutrition education for the pregnant woman or standards for the nutrition education of physicians.{135]

Because of the lack of awareness among health care professionals and the reluctance of most organizations to advocate that pregnant women follow sound nutritional guidance and refrain from taking drugs (unless absolutely necessary) when such advice is contrary to that given by a physician, hundreds of thousands of pregnant women unwittingly place themselves and their unborn at risk. It is not surprising that a major university study showed that approximately one million infants are at risk of needlessly being brain damaged every year in the U.S.[136] Since the study was basically confined to low-income populations, it did not consider the large numbers of affluent women who subject themselves and their newborns to needless pathology as a result of adhering to low-salt and/or low-calorie regimens, controlling their weight gain, and/or taking physician-prescribed drugs.

The practice of preventive medicine is probably more essential in the field of obstetrics than in any of the other medical specialties. A child born to a mother who is not exposed to proper obstetrical guidance is at risk of developing mental, physical, and/or behavioral abnormalities. Emphasizing the social and economic benefits of a practical approach to prenatal nutrition, the international publisher of perhaps the most widely circulated medically oriented publication, wrote:

Perinatal Support Services: pregnancydiet@mindspring.com