At the Salt & Pregnancy Forum of May 2006 (1), organized by EuSalt, Prof. Dr. Markus G. Mohaupt already underlined that pregnancy is no time to reduce salt intake and that additional salt may benefit women suffering from pre-eclampsia.

Recently, Prof. Dr. Mohaupt published a case study (2) showing that an additional salt intake of 20g stopped hypertension during pregnancy… In this case, a 33-year-old woman with normal renin activity was diagnosed with essential arterial hypertension 15 years ago. During the 6 month period before conception, her blood pressure was well-controllable by dual antihypertensive treatment. Throughout pregnancy, blood pressure recordings were collected daily, and at five weeks of gestation in her first pregnancy, she stopped all antihypertensive drugs. As a result, the average blood pressure increased, whereas the expected increase in aldosterone synthase activity in pregnancy did not show. Given this hypoaldosteronism, sodium supplementation aiming at 20g total NaCl intake per day was initiated, and pursued throughout pregnancy, and resulted in a decrease of the blood pressure during pregnancy.

After delivery, maternal blood pressure rose again, NaCl supplementation was terminated and antihypertensive treatment was reinstalled. The observation that blood pressure was responsive to NaCl supplementation is in line with the hypothesis that intravascular volume decrease causes increased blood pressure in pregnancy. The absence of the expected increase in aldosterone synthesis was associated with a mutation of the aldosterone synthase gene, similar to earlier findings in pre-eclamptic women. This persistenthypoaldosteronism together with earlier findings on NaCl supplementation led the researchers to supplement salt in this woman. This salt supplementation was associated with a reduced blood pressure throughout pregnancy. In addition to this case, Mrs Sabine Kuse, founder of a support group (1984) for women in acute state and after pregnancy with pre-eclampsia or HELLP-syndrome, and her team have been advising more than 20.000 women during their high-risk pregnancies over the past 22 years.

They found that in most cases, additional salt helped within hours. More importantly, during all those years, they haven’t seen one case where salt supplementation has caused negative effects. The worst effect was no effect. (1) Support for this critical role of NaCl intake during pregnancy, was already provided by Robinson in 1958, who found a reduced incidence of pre-eclampsia in pregnant women on a high salt diet (3).

This study introduced substantial data for bias in other studies, of which all data suggest that salt restriction during pregnancy does not seem promising for the prevention of pre-eclampsia. Or, as the study of Mohaupt et.al concludes: pregnant women with even subtle signs of volume deficiency might benefit from salt supplementation in pregnancy.

Footnotes:
1. EUSALT Newsletter. Salt, blood pressure and pregnancy: a critical relationship? August 2006.
2. Markus G. MOHAUPT et.al . Blood pressure reduction in pregnancy by sodium chloride. Oxford University Press, 2006.
3. M. ROBINSON. Salt in Pregnancy. Lancet, 1958, 1: 178 – 181.

Source: 4th April 2007 12:23:26 / Femalefirst.co.uk

See here: "Additional Salt Helps Reducing Blood Pressure In Pregnant Women With Low Aldosterone Level"

The following is reprinted from What Every Pregnant Woman Should Know, by Gail Sforza Brewer with Tom Brewer, M.D., 1977.

"Low Salt Diets: why they don't work" (p. 24)

Every day of her life the expectant mother, like every other man and woman, needs salt. Each of the trillions of cells that make up her body testify to this biological necessity. Like the cells of all species evolved from the sea, hers must be continually bathed in salt water to remain healthy.

Her unborn baby shares this legacy. Afloat in a sac filled with hospitable brine, the baby obtains all the salt it needs from the mother's circulating supply. The only way the essential salt will be in the mother's bloodstream is if she eats it. Salt is a component of many foods, in addition to being readily available in its commonest form, ordinary table salt. The placenta permits the transfer of salt from the mother's bloodstream to the baby's from the earliest weeks of pregnancy until the moment of birth.

Every person has many finely tuned mechanisms which work in the body to preserve the appropriate concentration of salt in and around each cell and in the bloodstream. These mechanisms are inter-related, so that a change in salt metabolism which affects one of them causes adjustments in others. Human salt requirements are widely variable depending on an individual's level of physical activity, state of health or illness, and the external temperature and humidity. There is a great deal of concern today about overconsumption of salt in our country. Studies have shown that excess salt intake from infancy onward may result from the intake of prepared foods and snack foods which contain a great deal of salt, but little else nutritionally, and have come to comprise a large part of the diets of many people. While the concern about over-salting may be legitimate in terms of overall public health, there is one group of people for whom over-salting is not a problem--pregnant women. In fact, pregnancy is one condition in which the body requires more salt in order to remain healthy. Numerous changes in the mother's body during pregnancy explain this increased need for salt.

Of first importance is the growth and development of the placenta. This organ, unique to pregnancy, makes possible the exchange of all nutrients and waste products between mother and baby. As the baby grows and requires more nourishment, the placenta increases in size to provide it. If the placenta does not grow well, neither can the baby.

As pregnancy progresses, the placenta needs a great deal more blood flowing through it in order to work efficiently. In normal pregnancy, the mother's blood volume must expand by more than 40 percent to meet this metabolic need. Salt is a chief element in maintaining this dramatically expanded blood volume. One of the properties of salt is that it causes the body to retain fluid which, under normal conditions, is retained in the bloodstream for use in placental perfusion. Salt restriction during pregnancy limits the normal expansion of the blood volume. A blood volume below the level needed to service the growing placenta produces disastrous consequences.

Depending on the degree of salt restriction and subsequent blood volume limitation, the placenta may grow slowly or not at all; develop areas of dead tissue (infarcts) which cannot function; be unable to accomplish the transfer of all needed nutrients to the baby; or even begin to separate from the wall of the uterus, causing hemorrhage and cutting off the baby's oxygen supply. Obviously, when the ability of the placenta to function is impaired, the baby's growth, development and even life are imperiled.

Clinical evidence for this view of the importance of salt in pregnancy was provided in 1958 by Dr. Margaret Robinson, a London obstetrician. Working in a public clinic, she conducted a study of 2,019 pregnant women, chosen at random. Half were instructed to reduce their salt intake; half to increase it. Information about which foods contain high amounts of salt was given to the mothers in the low-salt group. Dr. Robinson did nothing else by way of dietary counseling to influence what the mothers ate. She only asked them to report the amounts of salt they were eating.

Unfortunately, not all the high-salt foods on the restricted list are nutritionally deficient. For instance, many, like milk, eggs, salty cheeses, salty fish and salty meat products are important sources of essential high-quality proteins. Since this study was conducted with low-income mothers for the most part, the effect of banning these foods from the diet because of their salt content was also to ban the lower-priced sources of excellent protein. Consequently, when the mothers followed the diet and were unable to afford higher-priced protein foods, such as lean meat, they were not only on a low-salt diet but on a low-protein one as well. So, the outcome of this study is due not merely to salt-restriction alone, but to a combination of salt and protein restriction. Since imposition of a low-salt regimen on a pregnant mother may well mean protein deprivation as well, the results of Robinson's work are very significant:

The low-salt group had nearly three times more damaged placentas, two and a half times more toxemia and twice the number of infant deaths.

The high-salt group fared better in other ways. They had fewer delivery complications and even a reduced incidence of leg cramps during pregnancy than mothers in the low-salt group.

Salt in Pregnancy

	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

The inescapable conclusion is that dietary salt is an essential nutrient for the pregnant woman. It is required for optimum human reproductive efficiency. To restrict salt is to court disaster.

Dr. Robinson, while proving this important point, did so at agonizing cost to the families whose babies died due to maternal salt and protein restriction. Mothers in the low-salt group saw twenty-four more of their babies die--babies who might have been born healthy and strong if their mothers had happened to come into the clinic on another day.

Despite these findings many researchers today continue to demand that more studies like this be done on pregnant humans. Not satisfied with the wealth of supporting evidence from animal experiments conducted over the past fifty years [as of 1977], they propose studying the effects of drug therapy, protein restriction, calorie restriction, vitamin restriction, mineral restriction, etc.--all for the purpose of "seeing what will happen!" Their demands for "control" and "experimental" groups of pregnant mothers is clearly inhumane in light of the tragic consequences of just this one study, completed nearly twenty years ago [as of 1977]. Persisting in subjecting more pregnant women and their unborn to hazardous deprivation experiments, or refusing to improve the diets of "control" mothers known to be suffering nutritional deficiencies in their daily diets, is criminal. Because of mounting criticism of such projects from a few lone voices in the scientific community and the public at large, many American researchers associated with prestigious universities and international health agencies have moved their projects out of this country. A baby who dies or is damaged in Guatemala provokes less outcry than one whose life is taken in Boston.

Ruth Pike, a nutritionist at Pennsylvania State University, influenced by Robinson's work, decided to see if she could duplicate her findings in a highly controlled laboratory situation--using pregnant rats instead of human mothers as experimental subjects. Specifically, she wanted to describe changes in organs brought on by low-salt diets in pregnancy. Her experiments are significant because she did not restrict protein in the diets of the rats. Salt intake was the only variable in her two groups.

She described two specific effects. First, rat mothers who were salt-restricted gave birth to offspring of low birth weight. Second, rat mothers on low-salt diets evidenced profound changes in the cells of the kidneys and adrenals. Pike found that when she re-introduced salt to the diet three days before delivery, the rats did not exhibit these changes. The damage to the organs was reversed when salt was added back to the diet.

She also observed that rats whose diets contained little salt and who were presented with containers of salt water and distilled water at the same time chose the salt water first. Only after drinking enough of the salt water to provide the necessary amount of salt for their normal body functions did the rats move to the distilled water. Pike's observations should have been brought to the attention of American obstetricians long ago by ACOG. Such an action would have convinced physicians to stop handing out low-salt diets to their pregnant patients as a matter of course.

Ranchers, farmers and veterinarians have arrived at the same conclusions as Robinson and Pike through their own experience and experiments. This 1968 reminder in the Dairy Goat Journal emphasizes their practical approach to the question of dietary salt:

Salt is in the forefront of all feed additives. Both sodium and chloride, salt's two components, are needed in the nutrition and physiology of all animals, including man.

Without salt, life as we know it could not exist. With too little salt in the diet, depending merely on the small amounts of sodium and chloride inherently present in feeds, animals become unthrifty and in time go to pieces. Cows deliver weak calves, or even lose their calves. Cows actually die from salt starvation.

Researchers and people who work with animals would never presume to add a certain prescribed amount of salt to an animal's feed each day as a way of meeting that animal's needs. They follow the proven principle of allowing the animal's instinct for salt to operate. They set out salt blocks or buckets of crushed salt which the animals are free to lick as they feel the need. In this way, each animal's individual needs for salt are best met.

Humans have an identical salt-regulating mechanism which, when allowed to function, guarantees an adequate supply of salt to the body. Taste buds sensitive to salt are present on the tongue and inside the cheeks. When your body needs salt, your food tastes flat and unappetizing. This is a signal to add more salt to your food. In this simple way, nature alerts all of us to our metabolic needs for salt.

Should a person happen to take in more salt on a given day than she needs, a second salt-regulating mechanism is activated. Her kidneys respond automatically to the elevated salt concentration in the blood by allowing excess salt to leave the body in the urine. This built-in adjustment makes sure her body never becomes overloaded with salt.

Dr. Mary Jane Gray of the OB/GYN department of the University of Vermont Medical School has tested this salt-regulating mechanism in pregnant women. She tried to induce salt-overload in them and failed. Twenty-eight pregnant women were divided into two groups and followed for a month. Even with urging from the doctor to increase salt intake by means of salt tablets, capsules and syrups, the high-salt mothers retained no excess sodium in their bodies. Nor did any of them develop toxemia, although classic teaching has been that too much salt in the diet leads to toxemia.

There are few medical conditions for which the standard treatment includes salt restriction. High blood pressure (hypertension), heart failure and kidney failure are examples. When women with such conditions become pregnant, or when pregnant women develop such conditions, special care must be exercised by the physician to see that the mother obtains enough salt to allow her blood volume to expand normally without triggering undesirable side effects. In the case of hypertension, recent research [as of 1977] challenges the conventional wisdom. Dr. Lionel Schewitz of Michael Reese Hospital in Chicago reported in 1971 that even mothers with severe hypertension did better with liberal salt intake during pregnancy than when they were placed on rigid salt restriction and diuretics.

Otherwise healthy pregnant women may encounter some circumstances in which, though their kidneys are functioning normally, they may lose more salt from the body than is healthful. Many women report bouts of vomiting for a time during pregnancy, commonly during the first three months. Diarrhea from flu or other illnesses also results in excess loss of salt and water from the body. Or, if the mother lives in a hot climate, exercises strenuously, or works in a factory or laundry in high temperatures, she may sweat profusely. All these conditions boost the body's need for salt. If the mother does not take in more, salt-depletion will activate temporary salt-conserving mechanisms in the kidneys and adrenal glands. If salt deprivation continues, these organs can become exhausted and show signs of degenerative disease. The best way for each pregnant woman to be assured of meeting her individualized needs for salt is to follow the wisdom of the body and salt her food to taste throughout the pregnancy. The body's simplest salt-regulating mechanism, the taste buds, are the most reliable guides to managing this aspect of human pregnancy nutrition.

Why, then, do doctors continue to place mothers on low-salt diets? Firmly fixed in their minds is the "magic number" they have erroneously accepted as the upper limit of safety for pregnancy weight gain--twenty-four pounds. Exceed twenty-four and risk toxemia, difficult labor and maybe a lifetime of obesity. When their thinking is dominated by these concerns, physicians are likely to accept any practice that seems to control weight--even that of restricting one of the most vital substances in the body--salt. It seems unlikely tha the laws of physiology and biochemistry which govern human salt metabolism are suspended in the case of the pregnant woman. Yet doctors ignore these fundamental needs, and persist in viewing salt restriction as an easy, safe way to rid the mother of worrisome pounds.

The pregnant woman's problem is that her doctor has set artificial standards for weight gain and salt intake. In order to enforce these standards, he relies on her cooperation in a deliberate strategy of nutritional deprivation for the duration of her pregnancy. If she follows the diet, the protein-calorie deficiency it engenders will be further complicated by salt deficiency. After a time, her metabolism will be markedly altered due to physiologic stress caused by malnutrition. She will become ill. Her baby will suffer. The diet will have failed.

The low-salt, low-calorie diet doesn't work because it overlooks the body's physiologic salt-conserving mechanisms and brings about the very conditions it was designed to prevent:

1. High blood pressure: when salt is restricted below body requirements, the kidney reacts by releasing a hormone, renin, into the bloodstream. Renin influences other hormones which, in turn, cause the arterioles to constrict. The effect is to raise the blood pressure since the same amount of blood is being pumped with the same force through a smaller opening. The obstetrician worries about high blood pressure (hypertension) since it often accompanies one of the most dangerous pregnancy diseases, toxemia. By putting the mother on a low-salt diet he is inducing hypertension where there was none before.

2. Low-protein intake: not only does the conventional low-salt, low-protein diet directly limit the amount of protein available for the baby's growth and the mother's health by cutting back on her needed calories by one-third, but the low-salt provision sharply limits her range of food choices and makes the permitted foods less palatable. Her appetite wanes, so she will probably eat less than she could under the diet's rules. She will then be even more severely malnourished than a first look at the diet indicates. As her intake of protein falls, her liver becomes less able to manufacture circulating serum proteins, such as albumin, and albumin levels start to fall. As a result, water is lost from her bloodstream into the area surrounding the cells (interstitial space) and it appears that other substances in the blood, such as iron, are present in very high levels. Fluid lost from the bloodstream shows up as generalized swelling of tissues called edema. Edema caused by this fall in albumin levels is abnormal, a sign of disease (pathological). It is associated with metabolic toxemia.

3. "Excess" weight gain: the edema will increase as long as the woman's body is malnourished. Her kidneys excrete less water in the urine as they scramble to keep salt and water concentrations in the body within normal limits; the reabsorbed water cannot be held in the bloodstream since albumin levels are too low, so it leaks out into the tissues. Result: added swelling and added pounds.

A logical, effective alternative to this type of stopgap dietary meddling would be a program for pregnancy nutrition which respects physiology.

In order for an obstetrician to implement such a program in his practice, he would have to abandon traditional thinking and unscientific practices taught him by his professors in medical school. Instead, he would focus his efforts on preventive care--on getting each prospective mother to eat good foods to appetite and to salt her food to taste.

Doing so, though, would soon lead him to a confrontation with another aspect of his routine practice, the diagnosis and treatment of edema, or swelling. He would find, to his acute distress, that the vast majority of pregnant women who eat to appetite and salt to taste, whose diets provide the optimum amounts of protein, calories and salt, do swell during pregnancy--normally!

What Every Pregnant Woman Should Know available here

See here for the best treatment for pre-eclampsia

See here for more information on the hazards of the over-medicalization of normal childbirth

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

Prevention of Convulsive MTLP (Eclampsia)

	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

At the first sign of a rising BP, pathological edema, pre-eclampsia, IUGR, premature labor, or HELLP, a Brewer Diet counselor should sit down with the mother and help her to evaluate her lifestyle and her diet to see if any adjustments can be made to optimize the fit between her pregnancy, her diet, and her lifestyle. For example, to compensate for her salt and calorie losses, she can cut back on her exercise program and her work schedule, she can stay out of the heat (outdoors, at work, or at home), she can postpone a move until after the birth (and 6 weeks postpartum), and she can increase her salt/calorie/protein intake. One way that she can increase her diet intake is to add 200 calories and 20 grams of protein for each of the following situations:

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.

The above information is reprinted and adapted from the work of Agnes Higgins, and Gail Brewer's "The Complete Pregnancy Diet: Meeting Your Special Needs" from Eating for Two, by Isaac Cronin and Gail Sforza Brewer, 1983.

See here for more information on adjusting the Brewer Diet to fit your lifestyle

Eating for Two, by Gail Sforza Brewer and Isaac Cronin, available here

Please be aware that traveling and moving can break up 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.

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.

"Group 11: Salt and Other Sodium Sources--Daily Exchanges: unlimited" (p. 22)

Salt your food to taste. Cutting back on salt can cause a fall in the amount of blood circulating through your placenta, thus reducing the supply of nutrients passing to your baby. Too little salt in the diet leads to leg cramps as well, since all the muscles of your body require sodium for efficient action.

So often we hear that too much salt is bad for us and that we should be cutting down on it. Why, then, do you say pregnant women should salt their food to taste? (p. 46)

The last word on salt for nonpregnant people probably hasn't been written yet, but it definitely has for pregnant women. You need more of the sodium it contains when you're pregnant--ever-increasing amounts, actually, as your pregnancy progresses. Sodium helps keep your placenta adequately supplied with blood, enabling it to pump nutrients to your developing baby. The salt you shake on your food is just one source of the sodium you need. There is also a good amount in most high-protein foods, such as milk, meats, and seafood, and in some vegetables. Of course, the more highly processed foods you eat, the more sodium you're likely to be getting, since salt is used in these products both as a flavor enhancer and as a preservative. If you are a vegetarian and think you've been avoiding sodium by eliminating salt from cooking, but you use kelp powder and soy sauce for seasoning, you're getting an essential sodium load from both.

Your body signals when it needs more sodium by the taste buds on your tongue and in your cheeks that are sensitive to salt. When you need more, your food tastes flat and unappetizing, and so you add some salt. This is what we mean by salting to taste. We are not suggesting that you coat everything you eat with a mantle of salt! Although even if you did, it wouldn't do you any harm as long as your heart and kidneys are healthy and you take in enough fluids to keep your body in balance.

You have numerous mechanisms in your body to do just that, pregnant or not, because none of us takes in exactly the same amount of sodium day by day. There are wide variations, both in sodium supplied and in sodium needed. The temperature has a lot to do with how much you need on a daily basis. When it's hot, you lose up to 20 grams of salt a day in your perspiration. This must be replaced in your diet; otherwise your blood levels of sodium fall to perilously low levels.

That is just one example. By the same token, if you are in an air-conditioned building and happen one day to eat lots of foods that are high in sodium, it would be possible for your blood levels of sodium to rise too high--except that your kidneys act to eliminate the excess through your urine before it does any harm. This action in the kidneys is automatic, one of the many self-regulating features of our bodies that most of us know little about but which protect us from danger hundreds of times a day.

During pregnancy you need sodium to keep the correct concentration in your bloodstream (the amount of water in your blood that needs to be balanced increases by about 60 percent by the end of your pregnancy); to keep the correct concentration in the amniotic fluid that surrounds your baby (and that the baby drinks); to aid your heart, which is just a muscle, after all, and like all muscles needs more sodium when called upon to do extra work (like pumping all that extra blood around for months); and to help your leg muscles, which carry your extra weight (and often respond to lack of sodium by cramping very painfully--usually just after you've fallen asleep at night).

Incidentally, we are not the only people encouraging pregnant women to salt their food to taste [as of 1983]. The American College of Obstetricians and Gynecologists (ACOG) now agrees. The manual that explains basic guidelines for ACOG members, Standards for Ambulatory Obstetric Care (Chicago, 1977), states: "Sodium is required in pregnancy for the expanded maternal tissue and fluid compartments as well as to provide for fetal needs. The normal patient may use the level of sodium she prefers. Routine sodium restriction is not advised."

This is big news because for years routine salt restriction was the order of the day in obstetrics. Even now, five years after the ACOG changed its advisory to the profession, many doctors are still surprised to hear of it when it's brought to their attention. And popular magazines, newspapers, and other media also sometimes get caught publishing an article or small feature in a pregnancy column giving women hints on how to follow a salt-poor diet in pregnancy.

But if I salt my food to taste for nine months, won't that cause a lot of swelling from excess water retention? Many women cut out all added salt during the last few days of their menstrual cycles, anyway, because it helps get rid of that bloated feeling. Aside from the discomfort, isn't swelling a danger sign in pregnancy? (p. 48)

It certainly can be a danger sign--but only when the swelling is caused by not eating enough of the right foods (including sodium-rich ones) or by a medical condition that would cause swelling in a non-pregnant woman or a man as well, such as heart failure or kidney disease.

The swelling that accompanies the normal course of pregnancy while you are on the Brewer Medical Diet is attributable to an entirely different cause--your healthy, well-functioning placenta. The same hormones that you've noticed make you swell up somewhat just before your period (some women hold an extra 5 to 7 pounds of water) are made in ever-increasing amounts by your placenta as pregnancy goes along. By the eighth month, in the well-nourished mother, the placenta makes--every day--the equivalent of the hormones in a hundred birth control pills! This swelling is not hazardous to you or to your baby. In fact, it's a natural way for your body to prepare for labor and breastfeeding by storing fluids you may need to avoid dehydration if your labor lasts a long time and to establish and maintain quality milk production.

Though all swelling may look the same, the situation inside your body is critically different when you are swelling on a good diet. On a nutritionally sound diet your liver has all the building blocks it needs to manufacture adquate amounts of a protein, albumin, that holds water in your circulation--the primary means by which your increased blood volume needs are met during pregancy. The larger volume of nutrient-rich blood servicing your placenta results in the larger production of female hormones and, so, more water retention than in a mother with average nutrition. It is possible for your tissues to hold 10 to 15 pounds of fluid for this reason without causing much change in your appearance--perhaps the fine lines in your face disappear and your rings feel somewhat tighter.

This "hidden" water retention in the well-fed pregnant woman (plus the increased size of her baby) has seldom been accounted for in the charts that break down the components of average weight gain in pregnancy, so they typically show a total of 24 to 28 pounds, whereas women on the Brewer Medical Diet gain, on the average, 35 to 45 pounds. Of course, many women gain less and many gain more based on their prepregnancy weights, metabolism, and activity level. We do not use the average as a rule (either a floor or a ceiling) for weight adjustment in pregnancy; it only demonstrates that the average figure you see elsewhere fails to consider the additional, beneficial water retention that comes with a good diet.

When your diet is not meeting your nutritional needs, the internal events are exactly the opposite. If the liver is undersupplied with the nutrients needed to produce albumin (and this is one of the most complicated functions the liver performs, so it's one of the first to go when nutrients are scarce), it cuts back. This decrease in production is detectable by analyzing a sample of blood: anything below 3 grams per 100 cubic centimeters of serum indicates a problem. With less albumin circulating and drawing water into the circulation, water that should be held inside your blood vessels cannot stay there. Instead, it leaks out into your tissues. Voila! You're swelling up, and the scales tell you about the water you're retaining--but they don't tell you where it is. Nor do they tell you that your blood volume is falling below the needs of a healthy pregnancy and that your placenta is starting to malfunction because of the reduced amount of blood flowing through it.

The pregnant woman on a poor diet (or even one on a basically nutritious diet who is not eating enough to meet her calorie needs) is not swelling from the influence of an increase in female hormones generated by a generous, healthy placenta. She is experiencing a shift of essential body fluids out of her circulation and into her tissues. If the situation continues, her other critical body organs, like the kidneys, liver, heart, lungs, and brain, become adversely affected by the dwindling blood supply (the kidneys respond, for example, by raising the blood pressure), and her baby begins to suffer intrauterine malnutrition. Most commonly this situation is diagnosed after a few weeks when the baby's failure to grow is noted at subsequent prenatal appointments. The medical terminology for this condition is intrauterine growth retardation (IUGR). If caught early enough, the situation can be reversed with appropriate nutritional intervention--by getting the mother on a diet suitable for her pregnancy needs and keeping her on it for the rest of her pregnancy. This includes salting to taste.

This interconnection between the foods you eat, how your liver works to keep your blood volume expanded, and the transfer of nutrients to your baby via the placenta is central to every successful pregnancy. It is impossible for anyone to evaluate what's happening internally from looking at your swelling or pressing your shinbone to see if you have water retention. Laboratory work measuring your blood proteins and hematocrit reading must be done before any diagnosis is made.

Swelling on a good diet is a sign of health in pregnancy. So salt to taste as an integral part of your pregnancy nutrition program. Do not restrict salt. Do not take diuretics or appetite suppressants to control your weight. Any of these actions is a direct attack on the expansion of your blood volume and places you and your baby in jeopardy for the most serious pregnancy complications.

The ACOG statement says "normal" patients can use all the salt they want. When would a pregnant woman have to restrict salt? (p. 50)

If she had any medical condition that was causing a backup of fluid in her circulation. The major problems that cause this are failing kidneys or heart disease. These mothers have an excess of fluid in their circulation, and sometimes in their lungs as well, which means that by cutting way down on salt and all other foods containing sodium--plus some judicious diuretic therapy, in most cases--the excess fluid can be mobilized and eliminated. Of course, such and mother should be in the hospital, where her condition can be carefully controlled.

Salt restriction is not warranted in cases where the blood pressure is rising, unless there is also this fluid buildup in the bloodstream. More about this aspect of salt and medical management of complicated pregnancies appears in Chapter 6.

Does it make any difference if sea salt or refined salt is used? (p. 51)

No. Both contain the same amount of sodium, which is what we're primarily interested in here. However, some people prefer to avoid the additives in refined salt (added to make it easier to pour, for example) and so prefer sea salt. All salt, of course, was at one time in the sea, and sea salt retains all the trace minerals that naturally occur, including iodine. The trace minerals are stripped from refined salt in production, so make sure you select iodized salt when you buy it. This is especially critical in areas of the country where the level of iodine in the soil is low and people don't get iodine in their diet from any other source.

Do my sudden desires for pickles at midnight and pistachio ice cream for lunch have any significance in pregnancy? Is it O.K. to indulge? (p. 140)

Go ahead with pickles and ice cream. The pickles have a lot of sodium, which you need in increased amounts to help maintain your big, expanded blood plasma volume. The same applies to salted nuts, sardines, anchovies, aged cheeses, anything cured with salt or kept in brine. The ice cream, if it's a "natural" brand made with real eggs and milk, contains good protein and calories you need.

About the only food cravings that can prove a problem are those for nonfoods such as clay or laundry starch, or for highly refined grains and sugars that provide little but calories. Eating clay and starch is a culteral phenomenon: Young girls see their older sisters and family friends do it when they become pregnant, so they pick it up when their turn comes. Some students of this practice report that clay eating was a common African custom that probably originated in times of famine, just as a way of keeping the stomach full, thereby preventing hunger pangs.

Eating starch often substitutes for clay eating when clay is unavailable, as in metropolitan areas. Starch provides many calories, but it offers no other nutrients. It is a hazard in pregnancy because it fills the stomach without contributing anything to your protein, vitamin, or mineral requirements. The same can be said of most commercial baked goods, presweetened cereals, alcohol, soda pop, candy, syrups, and many prepared foods.

In general, choose foods from the market in as close to their natural state as possible. Cook them at home to preserve the most nutrients and satisfy your daily exchanges before you eat anything else. That way, your food cravings will not substitute for the foods that give you the most nutrition overall.

I've been going to my doctor for ten years and I really like him. He's never too busy to answer my questions. Last week, though, at my first prenatal appointment, he handed me a diet that he says he likes all of his pregnant patients to follow. It's so different from yours--I'm confused! Surely my doctor wants me to have a healthy pregnancy, but I don't understand how his nutritional advice could be so out of date: only 1,200 calories and very low-salt. It makes me wonder about the way he will view other things I feel strongly about (no monitor during labor, a chance to breastfeed right after birth, early discharge from the hospital, use of the birthing room, etc.). Should I try to talk this over with him? How can I find out if there are any nutritionally informed obstetricians in my area? (p. 141)

Talk it over with him by all means--he may be educable. And even if he turns out to be resistant to new concepts in prenatal care, that doesn't have to stop you from following the best diet possible anyway, on your own. In fact, this is exactly what women everywhere have done for decades in the face of medical advice that ran contrary to their own sense of self-preservation (the standard routine of gaining no more than 2 pounds a month, no salt, and various drugs to control appetite and swelling). Clearly, if every woman who had ever been told to follow such a regimen had actually followed it to the letter, the hazards of doing so would have become obvious to the entire medical community as well as to women themselves within a matter of a few years. There would have been precious few normal babies born!

It's ironic that the extent to which women have "cheated" on this type of diet in pregnancy is the extent to which they've stayed healthy. Most of the time, in order not to offend or antagonize the doctor, women never admitted to not following the diet; they just broke the rules and pretended to be doing without salt and only eating half of what their appetites dictated. And doctors, not having the benefit of knowing what the mothers were really doing as far as their nutrition was concerned, continued to hand out the inadequate diets, feeling assured all along that the diet was an integral part of their quality prenatal care practice.

The women who invariably wound up in trouble (and who still do today [1983], as calls to our hotline attest) are those who were extremely conscientious in carrying out the doctor's order: They became a high risk for all the malnutrition-related complications of pregnancy even if they had been very well nourished up until their encounter with the doctor's dietary advice. How this type of diet became a fixture in American prenatal care and the tragic consequences for the health of mothers and babies over the past twenty-five years were the subject of our first book, What Every Pregnant Woman Should Know: The Truth about Diets and Drugs in Pregnancy (New York: Random House, 1977). Read this book for a complete explanation of your doctor's training in these matters.

As far as your doctor's attitudes about labor and delivery are concerned, we haven't been able to notice any correlation: Even the most progressive doctors who subscribe to the most noninterventive style of obstetrics are not always sharp on their prenatal management when it comes to nutrition counseling. Just because someone is willing to attend you in a birthing room and gives your baby a bath immediately after birth is no guarantee that your nutritional needs will be understood as you progress through pregnancy. Nor can you automatically assume that all midwives are well trained in nutritional management. Every potential care provider you interview should be evaluated according to the same set of criteria: Do not assume that anyone takes your nutrition seriously unless you specifically ask about his or her practices. Until standards for nutrition education for midwives and doctors are made a routine part of the required training curriculum, it's every woman for herself and her baby. If this were not so, there would be no need for this book.

[Joy's note: I once worked with a homebirth midwife who was vehemently opposed to the use of the Brewer Diet, and often suggested to patients that they should cut back on their salt intake, and within 6 months of her joining our practice, we had 2-3 patients hospitalized for high blood pressure, pre-eclampsia, and/or premature contractions, which was highly unusual for our practice.]

We maintain an active referral network to individuals experienced in pregnancy nutrition counseling nationwide. Many of these people are childbirth educators and nurses who have completed our prenatal counseling seminar and file counseling reports with us. Others are physicians, midwives and dieticians who support the concepts and conduct their practices along the lines we describe in this book. As more and more women become sensitive to their pregnancy nutrition needs and actively discuss them with their doctors and midwives, the list of cooperative practitioners grows.

At this time, the referral service is informal: A mother with a good report on a doctor or midwife notifies our office. A member of our staff contacts the individual and determines by the use of a questionnaire whether placement on the list is warranted. Again, the referral is highly restrictive: We are concerned about the nutritional aspects of the individual's practice. Therefore, this person may handle the labor and delivery in ways that are not compatible with an individual mother's preferences.

To request a referral or to make a recommendation, write: the Foundation for Perinatal Education, Box 221, Bedford Hills, NY 10507.

[Joy's note: Since this was written in 1983, many changes have taken place, including the unfortunate death of Tom Brewer in 2005. It is possible that no one from the Brewer family receives mail at that address any more. So I suggest that anyone interested in a referral contact "BlueRibbonBaby.org" to see if they have a referral list.]

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

The following is reprinted from Metabolic Toxemia of Late Pregnancy: A Disease of Malnutrition, by Thomas H. Brewer, M.D., 1966 & 1982.

Note from Joy: Please note that the use of diuretics in pregnancy was much more common when this was first written. 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 and salt restriction 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.

Unfortunately, some areas of the "alternative medicine" community have 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 about the use of herbal diuretics in pregnancy

"Dietary Salt and Diuretics" (p. 72)

My own clinical experiences working with many normal and toxemic pregnant women have led me to the firm conviction that restriction of salt in the diet of pregnant women produces no clinical benefit. Several investigators in this country and in England and in Canada have recorded similar experiences. 43,44,45 Of course this does not apply to the women with significant cardiovascular or renal disease during pregnancy.

Salt restriction has some undesirable results, particularly when combined with the use of saluretic diuretics. Many women have told me that both physicians and public health nurses had told them not to drink milk because it contains too much salt. This is wrong, because milk is one of the most important and cheapest sources we have available for high biological quality proteins. A low salt diet is not very savory, and the patients often do not eat well when actually following such a diet.

It is in the hospitalized patients that one of the most glaring errors is often made in pregnancy nutrition. Here we have opportunity to provide the patient with an optimum diet planned and prepared by expert nutritionists. I have been in several hospitals in our nation where the routine management of the toxemic patient calls for a "low salt diet" which on inquiry is found to contain only 50 gm of protein. To reduce the toxemic patient's protein intake below that of the requirements of normal pregnancy is to make a grave physiological and biochemical mistake.

Figure 11 (Chap. 4, p. 52) demonstrates a common clinical phenomenon: a diuretic which causes the kidneys to excrete an excessive amount of sodium and potassium, and water associated therewith does not have any effect upon the underlying metabolic disorder in MTLP, for as soon as the diuretic is stopped, the sodium and water retention immediately recurs. A diuresis may blind the physician to the fact that the patient is really getting worse. Diuretics are absolutely contraindicated in the severely toxemic patient who has a contracted blood volume, low serum albumin and hemoconcetration. The following three cases [to be added to this website at a later date] are presented in detail to illustrate the clinical reality of these ideas. It was from the careful study of these and other similar cases that I began to crystallize my ideas about the pathogenesis of metabolic toxemia of late pregnancy and to turn from concentration upon sodium, water, diuretics and the kidneys to concentration upon nutrition and hepatic dysfunction.

43. Robinson, Margaret: Salt in pregnancy. Lancet, 1:178 (Jan. 25), 1958.

44. Mengert, W.F., and Tacchi, D.A.: Pregnancy toxemia and sodium chloride, Amer. J. Obstet. Gynec., 81:601, 1961.

45. Bower, David: The influence of dietary salt intake on pre-eclampsia. J. Obstet. Gynec. Brit. Comm., 71:123, 1964.

"Afterword to This Edition by the Author: Salt in Pregnancy" (p. 149)

Closely allied to the question of hypertension in pregnancy is the question of dietary salt, NaCl. Salt has been blindly restricted in the diets of pregnant women, and especially in MTLP, by Western obstetrics for over 150 years [as of 1982]. The classic work of Margaret Robinson at St. Thomas Hospital, London, "Salt in Pregnancy," (Lancet 1:178, 1958) convinced me that this traditional, blind salt restriction is wrong in human prenatal care. Consequently I had never advised pregnant women in my prenatal care-nutrition education program to "cut back on salt" nor did I ever use a low sodium diet. Robinson had reported twice as many perinatal infant deaths and two and one-half times more cases of "pre-eclamptic toxemia" among one thousand pregnant women told to follow a "low salt diet" compared to a thousand put on a "high salt diet." There were more abnormal placentas in the low salt group.

The work of Ruth Pike et al. at Penn State (Internatl. J. Gynecol. Obstet. 10:1, 1972), who produced low birth weight rat pups with dietary salt restriction alone and studied the renin-angiotensin-aldosterone system in normal and salt-depleted pregnant rats, convinced me that salt is an important essential nutrient for all pregnant mammals including human beings. Thus in 1972 I began to stress to my prenatal patients: "Salt to taste!" with the same enthusiasm and insistence that I had been using to promote high biological quality proteins, adequate calories and other essential nutrients found in a "balanced diet." (Obstet. Gynecol. 40:868, 1972)

Metabolic Toxemia of Late Pregnancy available here

The following is reprinted from The Very Important Pregnancy Program: a personal approach to the art and science of having a baby, by Gail Sforza Brewer, 1988.

I am a nursery school teacher in the twentieth week of pregnancy. For the past three weeks I've had persistent numbness, tingling, and at times the sensation that my fingers and hands are on fire. I can't even button the children's coats anymore! Is this related to my nutrition? My midwife said to cut out salt. (p. 123)

Even people who aren't pregnant experience a similar difficulty when they become deficient in B vitamins, particularly B6. It's called carpal tunnel syndrome because the nerve running through the wrist passes through a narrow tube, the carpal tunnel. In some individuals the carpal tunnel is considerably smaller in diameter than in others. So any situation that affects the tunnel of the nerve passing through it is more noticeable in such people.

John Ellis, M.D., author of The Doctor Who Looked at Hands (New York: Arco, 1980), treats carpal tunnel syndrome with three doses of B6 daily, 50 milligrams per dose. If no improvement is noted in a week's time, he believes the problem isn't vitamin related but is probably caused by the edema that is a normal part of pregnancy.

Swelling of your tissues, even though not too obvious to the casual observer at this point in your pregnancy, still can be significant enough to cause pressure on the carpal tunnel, compressing the nerve within. The tingling and numbness you describe are typical complaints when this happens. Do not cut down on salt: You need it to help maintain your expanded blood volume, the critical key to nourishing your baby.

It may help to apply a splint to your slightly flexed wrist must before going to bed. This will alleviate some of your discomfort for part of the day if you can discover a position that gives you a bit of relief. Apart from the very real loss of motor function (some women find it impossible to set the table, do dishes, fold clothes, type, or handle household appliances), carpal tunnel syndrome has no effect on you or the baby. It does not indicate the presence of any other type of pregnancy problem.

I'm an avid gardener and tennis player, but now I'm having such excruciating leg cramps every night that my legs still feel sore the next morning. Am I overdoing the exercise? I'm seven months pregnant. (p. 141)

No, it sounds like you're underdoing the salt! On a hot day when you're just sitting on the verandah, you can lose up to 20 grams of salt in your perspiration. If you're pushing a wheelbarrow, bending and pruning and wielding a spade or hoe, or putting away your opponents with aces on the court, you're losing even more. The sodium and chloride in the salt must be replaced for your body's electrolytes to remain in balance. As mentioned earlier, deficiencies of sodium during pregnancy can cause a reduction in blood volume.

Muscle cramps are among the classic signs that your sodium intake is not adequate for your needs. So-called "factory cramps" have been identified as a problem in industrial workers in England for over a hundred years. So even though you aren't operating a heavy machine on an assembly line, the combination of working out in the hot sun and participating in an active sport places similar stresses on your body. Increase your intake: Make a point to add extra salt to your morning eggs, to soups and sandwich fillings, and salad dressings, and sprinkle it generously over your dinner entree. You have nothing to lose but your leg cramps.

My due date is three weeks away and the doctor says my baby will easily weigh 8 pounds. He's becoming worried about one thing, though: I've started having marked swelling of my feet and legs (when the doctor presses in on my shinbone, the skin stays indented for a minute or two) and I can't get my wedding ring off anymore. Because I've been following your program, I know some swelling is normal owing to the hormones made by the placenta, but is this much still O.K.? The doctor says he no longer prescribes diuretics for swelling, but he wants me to stop salting my food at the table and in cooking and cut out milk and milk products because they're so high in sodium. Can I cut back just a little on salt, reduce my swelling somewhat, and still stay in the best condition for giving birth? (p. 160)

First, the amount of swelling you describe is perfectly normal if you're sure you're having everything from the basic diet exchange list every day and you haven't stepped up your activity so that you need more calories than before. Women with larger babies tend to have more dependent edema, that is, swelling of the feet and legs, just by virtue of the fact that the heavy uterus presses more on the veins that return blood to the heart, causing a pooling of blood and water in the legs. The best remedy for this (though it may not provide complete relief) is to lie down three or four times a day, for ten minutes at a stretch, with your legs elevated. Wear flat, soft open shoes such as sandals or bedroom slippers to avoid pinching your tender feet.

Under no circumstances should you cut back on your salt or start limiting your servings of sodium-rich foods. Just a couple of weeks on such a regimen late in pregnancy can bring about a reduction in your blood volume, triggering a rise in your blood pressure--just what your doctor does not want to see! [emphasis by Joy] Asking you to cut back just a little on sodium is like asking you to cut back just a little on oxygen. This is the stage of pregnancy when your sodium needs are greatest, and you can only throw the delicate balance you've maintained thus far into disarray by starting to deny yourself and your baby essential nutrients.

If anything, you might try adding more salt and extra servings of protein foods (Groups 1, 3, and 4 on the diet list), just in case you are falling the slightest bit behind on your diet. This can happen easily in the last month of pregnancy when your abdomen is so crowded--your appetite tapers off slightly without your really being aware that it's happened. Then your swelling becomes more marked. Excess swelling also commonly accompanies twin pregnancy. Are you sure your one big baby isn't two or more?

Other questions to consider are: Have you just moved? Are you working extra hours now in order to have a longer maternity leave after the baby comes? Have you been away on a trip with your husband--a second honeymoon before your family changes permanently? Have you been involved in a flurry of civic activities, commitments you made long ago and now have to carry through before you give birth? Have you been pushing yourself to get the baby's room ready, although you'd rather take a nap in the afternoon? All these situations demand extra energy from you and may absorb your attention to the point that you're skipping some snacks, or maybe even a meal or two. Get back on the track, adding extra protein and salt, and you will have the stamina to carry on as well as much less swelling to bother your doctor. Keep a careful food record for the next three days to see if you're really following the diet as you need to.

If you are well nourished according to the needs of your pregnancy, the only other reason for marked edema would be the rare medical disease that causes swelling even in the non-pregnant individual. Examples are heart failure, kidney diseases such as nephritis, and cirrhosis of the liver. In such a case, you would, of course, be experiencing other symptoms besides swelling that would lead your doctor to the correct diagnosis.

You can expect to have a postpartum diuresis, that is, dramatically increased urinary output, in the first two or three days following delivery. After your baby is born, you no longer need the reserve of water in your bloodstream and tissues, and this is the mechanism for excreting it. In other words, your swelling is not permanent. It is meeting a current need of your baby and will stand you in good stead during labor if you don't feel like drinking anything or have nausea. It is a protection against dehydration and shock in case you have some extra blood loss during labor or at delivery. Look upon your temporary discomfort as a sign that you have all the extra water you need to ensure your welfare and your baby's now and throughout labor.

I've tried to breast-feed twice before, but lost my milk within the first month both times, even though I nursed the babies whenever they cried as the women in our local breast-feeding support group suggested. I always thought that my diet had nothing to do with milk production--at least that's what most people say--but could my low-salt, calorie-restricted diet during pregnancy have dried up my milk? I continued to use no salt after pregnancy because of all I've read about the hazards of too much salt intake. What's the best diet for successful breast-feeding? (p. 170)

Just as we've done away with the "magic placenta" idea, we must now dispel the "magic breast" concept. Both are obstacles to good maternal and infant nutrition because they give the false assurance that the baby can be well nourished, first in utero and later at the breast, independent of what the mother eats.

The placenta can only transfer to the unborn baby the nutrients that are provided by the mother's diet. The breast, likewise, can only manufacture milk out of the raw materials in the bloodstream. If the basic building blocks of human milk are not present in sufficient quantities, then the mammary glands cannot produce it, no matter how often you put your baby to your breast.

I look to maternal nutrition first whenever someone asks about lactation problems, because it's likely to be the factor most people advising the mother think of last. Typically, the mother has either been on a low-salt diet during pregnancy and is continuing it while trying to breast-feed, or she is just so thrown by the erratic schedule a newborn entails that she's not keeping her diet up even though she may have the best intentions of doing so. She finds this out for herself by comparing her daily food intake with what's recommended in the diet. I see grazing as the most workable format for nursing mothers because they are likely to be awakened several times during the night, in addition to the numerous daytime feedings (12 to 15 nursings in a day is more the rule than the exception in the first few weeks), and eating something nutritious and drinking something to "prime the pump" every time you offer the breast is a habit successful nursing mothers cultivate.

Breast-feeding is really the second half of pregnancy. Like the first half, it represents a tremendous nutritional challenge to the mother who wants to have plenty of the highest-quality milk and plenty of energy to enjoy the breast-feeding experience, not to mention the rest of her family. As you well know by now, restricting sodium during pregnancy thwarts the normal expansion of the blood volume so essential to placental function. Restricting sodium during breast-feeding has the same ill effects on the amount of fluid you have available for milk synthesis. The "drying up" of your milk supply can be the sad result.

As long as your baby is dependent on you for the majority of his or her nutrition, you must continue to think of yourself as still pregnant. The nutrients that used to go to the baby through the placenta are now carried through the breast into your milk--but they still have to come from what you eat every day. I repeat: Eat good foods to appetite, salt your food to taste, drink to thirst, avoid any drugs or regimens that interfere with your nutrition, and exercise regularly. It's not yet time to modify your pregnancy routine.

The Very Important Pregnancy Program available here

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)

While veterinarians, farmers, and ranchers have clearly defined standards for the management of pregnant animals, no such standards exist for humans. A professor of animal husbandry stated:

In contrast, a widely distributed booklet for pregnant women reads: "(Your doctor) may prescribe medicines to help control your blood pressure and/or fluid retention."[128] To toxemic women the booklet suggests: "Do not use salt to season your food, either at the table or in cooking."[128]

Illustrating a case history of preventable mental retardation, a concerned obstetrician appealed to his colleagues for the immediate implementation of primary prevention through good nutrition as a routine, integral facet of obstetrical care. He wrote:

See here for the entire chapter from which this excerpt is taken, including the cited references

21st Century Obstetrics Now! Vol. 2 available here

Perinatal Support Services: pregnancydiet@mindspring.com