The following is reprinted from The Pregnancy After 30 Workbook, (Gail Sforza Brewer, Editor), 1978. (p. 25)

No matter how many years you have delayed your pregnancy, no matter how old you are when you become pregnant, there is one proven way to reduce the risk of complications for yourself and your baby to the lowest possible level: Follow an eating program adequate for your pregnancy.

Today, despite a growing understanding of nutrition on the part of many people, the question of what to eat when you're pregnant still provokes debate. And it seems that everyone has an opinion about it--even perfect strangers feel comfortable giving a pregnant woman advice about her diet! Meanwhile, the person most women turn to for accurate information, their doctor, often seems unable to answer questions about nutrition satisfactorily.

Understanding how your body works during pregnancy provides a foundation for an adequate nutritional program. Dynamic changes occur in your body at this time. Some of them, like the growth of your breasts and womb, are hard to miss! But others, because they happen invisibly, are rarely in the forefront of a mother's mind. In fact, few women are ever told that these changes have everything to do with the success of their pregnancies, and that they are of major significance from the point of view of nutrition. Three of these are critically important:

1. the development of the placenta

2. the expansion of the blood volume, and

3. the increased demand on liver function.

Any pregnancy diet recommendations which overlook these necessary adjustments create problems for both you and your baby.

To separate fact from fiction for yourself, take this short quiz and compare your answers with those provided at the end of the test.

	Pregnancy Nutrition Quiz Section I - Are the following statements True or False? 1. When a woman becomes pregnant, she should cut down on her salt intake. 2. A woman's weight gain in pregnancy must be controlled in order to reduce her chances of a difficult labor. 3. Taking prenatal vitamins and mineral supplements will satisfy a pregnant woman's special nutritional needs. 4. Swelling of ankles, fingers, and face (edema) is a danger sign in pregnancy calling for the elimination of salt from the diet. 5. A baby's length and weight at birth depends on the parents' stature. 6. Brain damage in babies is primarily caused by difficulties at the time of birth. 7. Mothers pregnant with twins should expect them to be born ahead of time and to weigh less than 5 1/2 pounds each. 8. Obstetricians receive training in applied nutrition for pregnancy as part of their residency programs. 9. A high-protein, low-calorie diet is desirable in pregnancy. 10. Pregnancy imposes a nutritional stress only on adolescents and women who were poorly nourished before they became pregnant. Section II - Choose the best answer. 1. During pregnancy a woman should gain: at least 24 pounds. no more than 24 pounds over her ideal weight. the number of pounds her doctor recommends. none of the above. 2. Babies have the lowest incidence of brain damage when their mothers gain: 0 to 15 pounds. 16 to 25 pounds. 26 to 35 pounds. 36 pounds or more. 3. Healthy mothers and healthy babies result when the mother's pregnancy weight gain follows a pattern of: 4 pounds a month throughout pregnancy. nothing in the first three months, 4 pounds a month for the next three months, then a pound a week until birth. 1/2 pound each week throughout pregnancy. none of the above. 4. Milk and eggs are good foods for pregnant women because: they contain all the known nutrients in a balanced form. they are low in sodium (salt). they are low in calories. they are not good foods for pregnant women because they are high in cholesterol. 5. When a woman follows a sound nutrition program for pregnancy, her chances of experiencing hemorrhage and poor postpartum healing are: increased. decreased. not affected in any way. dependent on her care in the hospital recovery room. 6. The most reliable indicator of a baby's future mental and physical development is: the Apgar score given at birth. the physical exam given at one month of age. the baby's weight at birth. the mother's weight gain during pregnancy. 7. Nausea or vomiting in early pregnancy is best helped by: eating plain crackers before arising. eating high protein snacks throughout the day and night. eating as little as possible. eating foods high in vitamin C. 8. Metabolic toxemia of pregnancy is caused by: malnutrition. a poorly functioning placenta. excess salt intake. excess weight gain in pregnancy. 9. The best advice for pregnant women about salt intake is: salt food to taste. salt food while cooking, but use none at the table. avoid all foods high in sodium and use none in cooking. take in no more than two grams a day. 10. A sound diet for pregnancy includes every day at least: 25 grams of protein and 1,200 calories. 40 grams of protein and 1,500 calories. 60 grams of protein and 2,000 calories. 80 grams of protein and 2,600 calories. Answers Section I - All statements are False. Section II - 1 -- d 6 -- c 2 -- d 7 -- b 3 -- d 8 -- a 4 -- a 9 -- a 5 -- b 10 -- d

The placenta is an organ unique to pregnancy. It begins forming in the early weeks of pregnancy in order to permit the transfer of nutrients, oxygen, and waste products between mother and baby. The placenta usually implants high on the back wall of the uterus so it presents no barrier to the emergence of the baby during labor. As the baby's need for nutrients increases, the placenta must grow to keep pace. By the end of pregnancy, a normal placenta is the size and shape of a dinner plate and approximately one inch thick, weighing between one and two pounds. It is exclusively a fetal organ, so, after the baby is born and it is no longer necessary, the placenta is expelled along with the membrane sac which enclosed the baby during gestation. For this reason, the placenta is sometimes called the afterbirth.

As the accompanying illustration shows, the placenta allows the circulations of mother and baby to meet intimately but never mingle. The baby's capillaries are continually bathed in a "lake" of the mother's blood. When necessary nutrients are at a higher level in the mother's blood than in the baby's, they diffuse through the one-cell thickness of the baby's capillaries and then procede to the baby's liver for combining into proteins and other building blocks essential to fetal growth. Likewise, when waste products reach a higher level in the baby's circulation, they diffuse back through the capillary network into the maternal circulation and are eventually cleansed from the bloodstream by her liver and excreted by her kidneys. The process of oxygen and carbon dioxide exchange works the same way. Keeping placental function up throughout pregnancy is one of the most important tasks the mother's body must accomplish. If the placenta begins to fail, fewer nutrients are available to the baby over any given period of time, so the growth and development of the baby are retarded.

See here for an illustration of the placenta and the a-v shunt which creates the lake of maternal blood

Added Volume of Blood Is Essential

Sustaining the lake of blood needed to service the ever-enlarging placenta requires a dramatic change in the amount of blood the mother has circulating in her body. At the placental site, it also involves a change in the way the mother's circulation works. Instead of having a closed capillary system, like the baby's, the mother's circulation is open. With each beat of her heart, jets of blood are pushed from her arteries against the surface of the placenta. Blood drains away from the placenta by way of the veins, much the same way that a tub drain catches water when you take a shower. This system is called an a/v (arteriovenous) shunt. Because quantities of blood are free at all times in the a/v shunt, the mother's blood volume must expand by 40 to 60 percent to provide enough for optimal placental perfusion and to keep all her other organs well supplied.

The baby starts to increase in size rapidly at the beginning of the fifth month. As the accompanying chart from Frank Hytten's The Physiology of Human Pregnancy, 2nd ed. (Philadelphia: J.B. Lippincott Co., 1971) shows, the rise in maternal blood volume also has a sudden upsurge during that month and continues to rise until just before birth. Any reduction in the amount of blood servicing the placenta impairs its ability to function and, ultimately, imperils the baby.

Nutrition enters the picture when you consider the problem of maintaining such an expanded blood volume. Your body calls into action its own salt-retaining mechanisms (reabsorption of sodium by the kidneys and an increased taste for salt through your taste buds), since salt helps keep water in the circulation.

A second factor is an increase in the synthesis by the liver of albumin, a protein which attracts water into the circulation. A blood volume below the levels needed to meet the demands of pregnancy (a condition called hypovolemia) is a serious problem. Not only is placental function threatened, but you also lose your built-in safeguard against dehydration and shock in the event of excess blood loss during labor and birth. Happily, hypovolemia is completely preventable when the mother's diet is adequate for pregnancy, especially with regard to salt and protein intake.

The liver's contribution toward a healthy pregnancy outcome is rarely discussed in childbirth education classes, yet three of its more than 500 metabolic functions have exceptional impact on the well-being of both mother and baby. The first is albumin synthesis. One of the most complicated processes the liver governs, it involves the selective combining of specific amino acids into protein molecules which maintain an appropriate amount of fluid in the bloodstream. Should the liver become damaged, albumin synthesis is one of the first of its functions to be affected. If the albumin levels in the bloodstream fall, water which should be in the circulation leaks out into the tissues causing abnormal swelling and puffiness (pathological edema) and leaving the blood volume contracted below the needs of pregnancy (hypovolemia). If the liver malfunction is severe and the blood volume continues to shrink, organs throughout the body are adversely affected by the reduction in blood flow. For instance, in the kidneys, a reduced blood volume results in elevation of bood pressure.

The Liver Must Handle Hormone Overload

A second important area handled by the liver is hormone metabolism. Clearing from the body a staggering load of female hormones manufactured continually by the placenta (the equivalent of 100 birth control pills a day!) requires that the liver attach fat-soluble hormones to other molecules, thus making them water soluble. Then the kidneys can excrete them in the urine. If the liver falls behind in this task of hormone clearance, they can back up in the bloodstream and tissues and reach toxic levels.

Following a pattern similar to that for clearing hormones, the liver must also cleanse the bloodstream of toxins which originate in the lower bowel. Since a slow-down in the process of digestion is a well-known phenomenon in pregnancy, these substances have a more favorable environment in which to develop, thus increasing the stress on the liver.

The only way to meet the stress imposed by this increased metabolic activity is by attending to your diet. The stress on the liver increases as pregnancy advances; so you need more protein, calories, vitamins, salt, and other minerals in the last half of pregnancy than you do in the first half when the baby, placenta, and blood volume are still relatively small. In many ways, the liver works overtime in the second half of pregnancy to meet the physiological demands and adjustments necessary to the health of both you and your developing baby.

Inadequate nutrition, especially lack of high-quality protein, during this critical period can result in severe metabolic derangement and disease. Metabolic toxemia of late pregnancy (MTLP) and abruption of the placenta (separation of the placenta from the uterine wall before the birth of the baby) are two life-threatening complications of pregnancy which result from the hypovolemia and liver dsyfunction brought on by malnutrition.

Misunderstanding of the role played by malnutrition in the onset of these and other obstetrical and pediatric problems has blocked efforts to establish standards of nutritional management in pregnancy. Many obstetricians remain ignorant of the advances made in nutritional science over the past 50 years [now 80 years], clinging to outmoded prenatal regimens, which do not recognize the nutritional stress pregnancy imposes on every woman. In many instances, these regimens (usually featuring low-calorie, low-salt diets and use of diuretics to combat swelling) were originally advanced as ways of preventing MTLP and abruptions. However, it is now clear that such dietary advice brings about the very conditions it was supposed to prevent by inducing malnutrition in pregnant women who may have been perfectly healthy before beginning to follow the physician's advice!

Baby's Brain Grows Most Rapidly in Last Two Months

Keeping an adequate supply of nutrients available to the growing baby is critical during the last eight weeks of pregnancy when the baby's brain is growing at its most rapid rate ever. Cells are proliferating and interconnections between them are being laid down. Research done in England over the past 20 years [as of 1978] has shown that even mild degrees of maternal undernutrition in these last few weeks of pregnancy can adversely affect this phase of the baby's brain development. So, even the mother who has been eating well up until the last two months of pregnancy can still give birth to a damaged child if she follows an uninformed physician's order not to gain another ounce before delivery.

Focus on Nutrition, Not Pounds

While the number of pounds gained during pregnancy says nothing about the quality of the mother's diet (you can gain weight by eating lots of empty calories or by eating lots of nutritious foods), the National Institutes of Health Collaborative Study of Cerebral Palsy and Other Neurological Disorders found in 1968 that mothers who gained 36 pounds or more in pregnancy had the lowest incidence of low birth weight and brain-damaged children (see chart). For this reason alone, doctors should abandon the practice of restricting a pregnant woman's weight gain to any prescribed number of pounds. Instead his efforts and concern should be redirected toward insuring that each woman obtains a diet adequate for her pregnancy.

When the focus is on nutrition, not pounds, weight gain will take care of itself. Some mothers, overweight at the beginning of pregnancy, may even lose a few pounds during pregnancy when their menu choices are made from higher-quality foods. The idea that every pregnant woman should conform to some ideal weight gain total or pattern disregards the incredible variability of metabolism, activity levels, and food choices that can characterize normal pregnancy.

As the accompanying chart shows, British investigators of normal physiological adjustments in pregnancy found that patterns of gain in the last half of pregnancy ranged from weight losses to more than 40 pounds gained. Since all the mothers included in this study had normal pregnancies and normal babies, it is obvious that pounds gained or lost per se are not the critical issue affecting maternal and infant health. The important factor is what the mother actually eats, day by day.

The foods you eat every day of your pregnancy play a critical role in your health; in the health, growth, and development of your unborn baby; in your labor and delivery; and in the health and future development of your newborn baby. Most medical personnel in the United States today have not been made aware of this fact despite the extensive research done in the last half-century confirming it [as of 1978]. Being pregnant, you can't afford this type of skepticism because pregnancy puts a special nutritional stress on every woman regardless of her age, health status, or previous number of children. Failure to meet this increasing daily stress with enough good foods, salt, and water leads to many nutritional complications of pregnancy, including difficulties in labor and delivery, which harm both mother and baby.

Pregnancy Complications Due to Malnutrition

Most doctors and nurses in the United States today don't recognize that a large majority of these complications are directly caused by malnutrition during pregnancy and are hence preventable! In fact, the idea of prevention of pregnancy diseases by nutritional means alone is likely to be regarded in all our teaching medical centers as faddism lacking scientific proof. Therefore, all pregnant women who receive prenatal care influenced by this indifference to applied nutrition are at much higher risk than women whose nutrition receives top priority as a routine part of their prenatal care.

If you have passed your thirtieth birthday, you will be considered as even a higher risk from the point of view of several common problems which are directly related to your diet during pregnancy: metabolic toxemia of late pregnancy (MTLP), hypertension, diabetes mellitus, and obesity. When you understand the role of diet in the prevention of MTLP and in the correct management of the other problems, you and your baby will no longer be in this high-risk category. In fact, with correct nutrition and drug practices all through pregnancy, you will be an even lower risk than average.

	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

Metabolic Toxemia of Late Pregnancy (MTLP)

I identified this as a specific disease entity in 1966. It is primarily a disease of the liver and characterized by a history of malnutrition, nausea and vomiting, low blood proteins (especially low serum albumin), and low blood volume (hypovolemia) which causes a marked reduction in blood flow to the placenta, kidneys, and other organs. It occurs in the last half of pregnancy, more often in the seventh to ninth months, and disappears a few days after delivery.

As a result of the hypovolemia and liver malfunction, the mother's blood pressure rises as the disease progresses, water and salt are retained abnormally, and protein appears in the urine. In the severest cases hemorrhages develop in the mother's liver and brain; convulsions, coma, and maternal and fetal deaths occur. This disease was previously termed toxemia of pregnancy or preeclampsia/eclampsia. Eclampsia, from the Greek word meaning a flash of light, was used for the severest form of the disease when the mother had convulsions and/or coma. Preeclampsia was used for the nonconvulsive stage characterized by excess water retention (edema), high blood pressure, and protein in the urine. Preeclampsia, as used by doctors and nurses in the United States, is a poorly defined entity, really a syndrome, because edema, high blood pressure, and protein in the urine occur commonly in human pregnancy from many other causes than MTLP.

Winslow Tompkins at the Philadelphia Lying-In Hospital reported in 1941 his success in the total prevention of preeclampsia/eclampsia by a sound, commonsense nutrition program for all women who came to his clinics. (See Nutritional Deficiency in Pregnancy.) Reginald Hamlin in Sydney, Australia, was able to prevent eclampsia completely by a nutrition program in the public prenatal clinics of the Women's Hospital, Crown Street, London (Lancet 1:64, 1952). Dr. Robert Bradley in private practice of OB/GYN in Denver, Dr. Henry Davis in general practice in Carson City, Nevada, and I in Contra Costa County, California, have had similar experiences. (See Prevention of Convulsive MTLP [Eclampsia].)

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

True Faddism in Treating MTLP

Failure to recognize the role of malnutrition in causing MTLP leads doctors and nurses down a blind alley of true faddism with the still universal use of low-salt, low-calorie diets; blind weight control to some magic numbers; and the use of harmful salt diuretics (water pills) and amphetamines to suppress the pregnant woman't normally good appetite. This irrational approach to management of the pregnant woman's diet has been termed Thalidomide II because it is so damaging to the unborn baby. I was able to prevent MTLP by throwing out of our county prenatal clinics all aspects of this regimen in favor of commonsense, applied nutrition as described here.

For further information, contact NATIONAL TOXEMIA HOTLINE (914) 271-6474. This is a service of the Society for the Protection of the Unborn which provides free consultation about suspected cases of metabolic toxemia for pregnant women, medical personnel, and researchers. Review of medical records and methods of medical management are included in the service.

Note from Joy: Unfortunately, this organization no longer exists, and neither does this phone number. However, you could email me with questions, through Perinatal Support Services, or you could have questions answered through the "Pregnancy Hotline" on the Blue Ribbon Baby website.

Perinatal Support Services

Blue Ribbon Baby "Pregnancy Hotline"

Hypertension in Pregnancy

Pregnant women whose blood pressures reach 140 systolic and/or 90 diastolic (140/90) are considered by most doctors and nurses to have high blood pressure or hypertension. Since women with MTLP may have convulsions and die with a blood pressure of 140/90 or even lower, such blood pressure readings in pregnancy are always cause for great alarm on the part of doctors and nurses. However, many pregnant women have hypertension without any other sign or symptom of MTLP. This may be caused by essential hypertension present long before pregnancy or it may develop during pregnancy--or be detected for the first time during pregnancy if the woman hasn't had her blood pressure checked for a long time.

A well-nourished pregnant woman may develop hypertension from acute anxiety or psychic stress, that is, from some traumatic event in her life, from being worried about the outcome of her pregnancy, from the discomforts of labor and delivery, or just from having her blood pressure checked by a doctor. In such circumstances the doctor's usual diagnosis is pregnancy-induced hypertension (PIH), which is not a specific disease entity such as MTLP. Adding to the confusion is the current fad of diagnosing the hypertension of metabolic toxemia of late pregnancy and the disease itself merely as PIH.

This is a very important point for every pregnant woman to understand because this current confusion leads to totally irrational and harmful methods of treatment of the hypertension with low-salt, low-calorie diets; blind weight control; and salt diuretics; methods which reduce the mother's blood volume and actually cause a superimposed MTLP. The hypertensive woman must be protected from malnutrition throughout pregnancy like every other woman.

Decreasing the risks to the hypertensive pregnant woman with a battery of complicated and expensive biochemical tests is the modern doctor's preoccupation--without any real concern for the woman's nutritional status. As a consequence, the results of the tests are often misinterpreted. For example, Iyengar in India has shown that the urinary excretion of estrogens in malnourished pregnant women increases dramatically when their nutrition is improved with more good foods. Doctors commonly order such estrogen excretion studies without ever recognizing the role of malnutrition in causing the low excretion of these pregnancy hormones, a result of the reduced blood volume following a low-calorie, low-salt diet and diuretic "therapy"!

No amount of diagnostic testing and/or monitoring of mother and baby in the uterus can insure the adequate nutrition of the hypertensive woman nor protect her and her baby from the disastrous consequences of MTLP, premature separation of the placenta, premature delivery and other nutritional complications--but good foods with adequate salt and water can.

It is important to remember that no matter what medical problems are associated with pregnancy, the nutritional stress remains and must be met every day. Low-calorie, low-salt diets; weight control; and salt diuretics are generally contraindicated in hypertensive women with a rare exception: when the woman's blood volume is abnormally increased as in severe kidney diseases or congestive heart failure. Such women must be treated in the hospital.

Other rare medical causes of hypertension such as malignant hypertension, brain tumors, and pheochromocytoma (a rare tumor of the adrenal gland) also require careful medical attention in a hospital. Except for these rare medical diseases, a woman hospitalized for hypertension, with or without MTLP, must refuse the low-calorie, low-salt diet and diuretic regimen which will directly harm her and her unborn baby.

Diabetes Mellitus in Pregnancy

Note from Joy:In this section, Dr. Brewer is not referring to "Gestational Diabetes". Rather, he is referring to "Type 1 diabetes" or "Type 2 diabetes", conditions which exist from before the pregnancy.

That good nutrition is the key to successful outcome of pregnancy is nowhere better demonstrated than in women with diabetes mellitus. In Philadelphia, Garfield Duncan, M.D., for years a leading expert in diabetes, was able to prevent metabolic toxemia of late pregnancy (MTLP) in diabetic pregnant women by good management. He advocated each woman have 2 grams of high-quality protein per kilogram of body weight (about 120 grams for the average woman) and at least 2,200 calories daily. Insulin requirements vary greatly; each woman needs the care of an internist to help the obstetrician in diabetic management which must be individualized. Adequate exercise is of great value in controlling diabetes during pregnancy.

We know that poorly controlled, malnourished diabetic women often develop MTLP, fatty liver, stillborn babies, congenital anomalies, excess fluid in the amniotic sac (hydramnios), severe infections in both mother and baby, and acidosis with excess ketone bodies in blood and urine. It is also clear that low-salt diets, low-calorie diets, and salt diuretics are harmful to the pregnant diabetic and can quickly lead to dehydration, lowered blood volume (hypovolemia), and even to a superimposed MTLP. Diuretics can cause direct damage to the pancreas and must be avoided by all pregnant diabetics. There is no scientific evidence that female hormones (progesterone and estrogen) are of any value in the management of diabetic pregnancies; their harmful effects are being widely recongnized today (See Barbara and Gideon Seaman's Women and the Crisis in Sex Hormones, New York: Rawson, 1977.)

Obesity in Pregnancy

The key to understanding the risk of obesity in pregnancy is the concept of the adequate no-risk diet. If you are overweight when you become pregnant, there is no real increased risk if you can eat an adequate diet all through pregnancy. This idea flies in the face of convention in the United States, where the obese woman is arbitrarily branded high risk for developing metabolic toxemia of late pregnancy (MTLP) and for having a hard time in laobr and delivery. Such a woman who is harrassed by doctors and nurses into starving herself and her unborn baby via the low-calorie, low-salt diet and diuretic regimen does then, in fact, become a high risk as predicted. Her pregnancy is made miserable by constant reminders about the supposed hazards of being overweight while she is told nothing about the real hazards of malnutrition for herself and for her baby.

Obese women are, in fact, protected in a sense from one important kind of malnutrition during pregnancy: calorie deficiency. It has been shown in thin, underweight women with few fat stores to draw on that there is an increased risk of MTLP, low birth weight, and brain damage in their babies. If the obese woman eats a good diet, with adequate proteins, carbohydrates, vitamins, salt, and other minerals, she may actually lose a few pounds during pregnancy while producing a healthy, full-term baby and remain in good health herself. This is not achieved by worrying over pounds gained, by rather by focusing on the quality and adequacy of her diet.

Weight Gain, Dietary Salt, and Water Retention (Edema) in Pregnancy

How much weight should a woman gain during a normal pregnancy? This is a common question which has worried women in the United States for a long time. It is clear now that normal pregnancy can happen over a wide range of weight gain. As we have seen, obese women may lose a few pounds while following an adequate, balanced diet, while thin, underweight women may normally gain 50 or more pounds. Women with twins who have full-term pregnancies often gain over 60 pounds with normal pregnancy outcomes for both mother and babies.

We know that pounds of weight gain are of minor importance compared to the adequacy of the diet for the individual pregnant woman. There is no scientific basis for the universal fad of setting up any magic numbers or patterns of weight gain as goals in human pregnancy nutrition. If such a weight limit in numbers is set up arbitrarily, the danger comes when the pregnant woman reaches or exceeds the numbers too early. She thus may be coaxed or threatened into starving herself and her unborn baby during the last critical months and weeks when the nutritional stress is greatest in terms of quantity.

In my clinics through some 7,000 pregnancies, among women never given any numbers of pounds as goals, who were constantly encouraged to eat good foods in response to appetite and to salt their food to taste, where salt restriction and salt diuretics were not used, the usual weight gains in normal pregnancies fell in the 35- to 45-pound range. Normal pregnancies were observed in women who lost five pounds and in women who gained 80 pounds. About 50 percent of normal women gain 20 pounds by the end of the fifth month.

Margaret Robinson, an OB/GYN doctor in London at St. Thomas Hospital, showed us how important dietary salt is for human pregnancy to maintain the health of mother, baby, and placenta. (See the graph Salt in Pregnancy.) She found that salt tablets would usually relieve leg cramps in pregnancy and that depriving women of salt led to an infant death rate twice as high as that observed in women encouraged to eat salt during pregnancy.

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

With a thousand women in each group, "low-salt" and "high salt," the findings were highly significant, if sad. Among women in the low-salt group, there was 2 1/2 times more toxemia of pregnancy and two times more premature separation of the placenta. Twice as many babies died in the low-salt diet group, among women told experimentally to restrict their intakes of salt and salty foods. It is incredible that 20 years after this study [as of 1978], low-salt diets remain in virtually universal use by physicians giving prenatal care.

Normal pregnant women, especially in the last half of pregnancy, retain water to such an extent that they experience swelling of their feet and ankles, fingers and hands, and even of the face. This normal water retention, caused by physiologic changes in the body (see chapter 4), is often mistaken for water retention associated with malnutrition and MTLP. This leads to a great deal of confusion among pregnant women, doctors, and nurses alike. Deficiencies of protein, calories, certain vitamins, salt, and water can all lead to abnormal water retention--not just excess salt in the diet!

Dietary salt restriction is therefore completely irrational in both toxemic edema and normal, physiologic edema. In MTLP, scientific treatment involves correcting the dietary deficiencies with good foods and salt when indicated while physiological edema requires no treatment. The use of low-salt diets coupled with salt diuretics represents a grave error which has not been recognized and corrected by the medical profession. Therefore, each pregnant woman must take responsibility for her own good nutrition. This is easy to accomplish with a proper understanding of these controversial questions of weight gain, water retention, and dietary salt.

The "no-risk" pregnancy diet provides all the nutrients you need by eating to appetite from the four[teen] basic food groups and resisting the temptation to substitute less-nutritious foods. By seeing that you eat well, you protect yourself and your baby from the known hazards of malnutrition during pregnancy.

The Pregnancy After 30 Workbook available here

See here for details from several studies regarding the link between nutrition and pre-eclampsia

See here for a timeline of the Brewer Diet development

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

See here for more information on the links between prematurity/low birth weight/pre-eclampsia and inadequate nutrition

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 (we usually had possibly 1 case per 1-4 years, if I recall correctly).

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.

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

References

Antonov, A.N. "Children born during the siege of Leningrad." J. Pediatrics 30:250, 1947.

Bletka, M. et al. "Volume of whole blood and absolute amount of serum proteins in the early stages of late toxemia of pregnancy." Amer. J. Obstet. Gynecol. 106:10, 1970.

Brewer, T.H. "Limitations of diuretic therapy in the management of severe toxemia: significance of hypoalbuminemia." Amer. J. Ob. Gyn. 83:1352, 1962.

Brewer, T.H. Metabolic Toxemia of Late Pregnancy: A Disease of Malnutrition. Springfield: Thomas, 1966.

Brewer, T.H. "Metabolic toxemia of late pregnancy: a disease entity." Gynaecologia 167:1, 1969.

Brewer, T.H. "Human pregnancy nutrition: an examination of traditional assumptions." Aust. N.Z.J. Obstet.Gynaecol. 10:87, 1970.

Brewer, T.H. "Human maternal-fetal nutrition." Obstet. Gynecol. 40:868, 1972.

Brewer, T.H. "Consequences of malnutrition in human pregnancy." Ciba Review: Perinatal Medicine, 1975, pp. 5,6. (Ciba-Geigy, Basel)

Brewer, Tom. "Toxemia--a disease of prejudice?" World Med. J. 21:70, 1974.

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