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The following is the "Introduction" reprinted from Eating for Two, by Isaac Cronin and Gail Sforza Brewer, 1983.
"A Cookbook for Pregnancy: The Medical Reasons", by Tom Brewer, M.D. (p.ix)
On my list of concerns about my pregnant patients' welfare, nutrition ranks second only to breathing. The reason is simple:
well-nourished women develop far fewer complications in pregnancy, have more efficient labors, and give birth more easily
to healthier babies than do their poorly nourished sisters. This makes my job as an obstetrician much easier--and a lot more
enjoyable! I am always interested in anything that will assist mothers in improving their nutrition. This cookbook is such
a tool.
This cookbook is not like any other cookbook in the world. Far more than a collection of delicious recipes (though it is,
indeed, that), it is a comprehensive eating plan for pregnancy, designed to provide all the nutrients needed during every
day of gestation to keep you and your baby in good health. In other words, it is an insurance policy, a form of protection
against some of the most common and most serious problems that could befall you or your unborn baby--those caused by poor
nutrition.
Research done over the past fifty years [as of 1983], including some of my own, has made it increasingly clear that if the
mother's diet is inadequate in any of several different ways, these difficulties may result:
No mother knowingly puts herself and her baby at higher risk for these complications. With very few exceptions, the mothers
I've counseled about the importance of their diets have appreciated the information and put it into daily practice for the
rest of their pregnancies. You will be able to do the same for yourself in your own kitchen when you use this cookbook as
the basis of your pregnancy meal-planning.
In my own practice as director of a prenatal nutrition education program in the public prenatal clinics of the Contra Costa
County (San Francisco Bay area) Medical Services between 1963 and 1976, I did research and managed over seven thousand pregnancies
using the pregnancy nutrition basics presented in this cookbook. I learned a great deal from my patients, their friends,
and their families after I adopted a seminar-style format for nutrition counseling, with individual follow-ups with each expectant
mother as part of her regular prenatal visits. This method of working brought the authority of the doctor to bear on the
mother's attitudes toward nutrition, and made concern for the mother's nutrition an ongoing part of her care, not merely a
one-time discussion or just a diet sheet handed across a desk.
Because I was doing obstetrics with sound nutrition as my first point of reference, I viewed my detailed knowledge of each
patient's diet as essential medical information--just as important as all the other routine biochemical tests (blood
work, tests on urine, other laboratory workups) and physical assessments (weight, blood pressure, palpation of the abdomen,
internal examinations) that constitute good prenatal care. In fact, it soon became apparent to me that many of these standard
tests and assessments are greatly affected by the status of the mother's daily diet, and that women who follow excellent diets
often "test out" differently than those whose diets are less nutritious. In short, I began to question the "normality" of
the numbers given for many standard tests since those numbers had been determined without regard for the nutritional status
of the subjects. So, for example, when I knew the mother's diet was excellent, I learned not to worry about a red cell count
(hematocrit) in the thirty to thirty-three per cent range at the eighth month of pregnancy, even though the standard numbers
said the count should be much higher. I realized that the well-nourished mother has a more greatly expanded plasma volume
(the water component of the blood) than had previously been recognized, so her red blood cells were somewhat diluted.
Learning not to panic in the face of such test results, and instead re-evaluating the basis upon which the test results had
been obtained, became a constant part of my clinical research and practice in those years. It was a hard part of the work,
because medical training is so authoritarian--it encourages the student to replicate the exact method taught by the professor.
It was also hard because for decades my specialty, obstetrics and gynecology, has been primarily surgical--with little reference
to the internal relationships of the body systems that support a pregnancy, and most attention paid to emergencies that often
surface only at the time of labor. I became firmly convinced that not only was nutrition important to the successful outcome
of the nine months of pregnancy, but it also held great promise in preventing so many of the ost common conditions that send
women rushing to emergency rooms in the middle of the night (see list given previously).
My own research specialty has been in a disease that I term metabolic toxemia of late pregnancy (MTLP), but which is
called by many other names around the world: in England, pre-eclamptic toxemia (or, PET); on the Continent, EPH
gestosis (edema, proteinuria, and hypertension of pregnancy); also known as pre-eclampsia/eclampsia (from the Greek
for "flash of lightning", referring to the sudden convulsions which, to ancient physicians, seemed to strike the pregnant
woman like lightning bolts from the blue), or, more generally, "toxemia of pregnancy" (a very broad term applied to several
different disorders which can be caused by many unrelated diseases).
I became interested in the relation beween maternal nutrition and this disease while a third-year medical student at Tulane
in 1950. My ob/gyn instructor, Dr. James Henry Ferguson, had been studying the backgrounds of women who had died in rural
Mississippi of eclampsia (the convulsive/coma stage of sever MTLP). In his lectures to us, he noted the terribly inadequate
diets of the mothers, diets he had reconstructed after talking with member of their families, public health workers who had
known them, and, in some cases, friends with whom they had been living or working. Most of the eclampsia victims had been
living or nothing but fatback, field peas, water gravy, an occasional plate of greens, candy and soda water. Deficient in
most essential nutrients except calories, this diet--and urban variations of it--was starting to be linked with onset of eclampsia
in work being reported from many other medical centers, including Harvard (work done by the internist Maurice B. Strauss,
later a medical school dean at Tufts), Philadelphia Lying-In Hospital (research by Winslow Tompkins, then chief of ob/gyn,
later director of the Children's Bureau in the U.S. Department of Health), and the University of North Carolina (papers by
Robert A. Ross, later to become president of the American College of Obstetricians and Gynecologists).
It was a time of great interest in the possibilities of the new science of human nutrition--particularly with respect to the
role of good nutrition in the prevention of medical diseases--so, like students everywhere, I accepted my professor's appraisal
of malnutrition as the possible culprit in eclampsia and checked his theory by asking women hospitalized on the toxemia wards
at Charity Hospital in New Orleans what they'd been eating before they became ill and entered the hospital. Ferguson's diet
list was repeated to me again and again. The women also told me they had been unable to eat anything for a few days before
they were admitted. They complained of severe stomach aches and lack of appetite, commonly followed by a day or two of acute
nausea and vomiting. These mothers weren't just malnourished. They were literally starving. And our treatment at the time
(low-salt, low-calorie diets and diuretics designed to eliminate the massive swelling and bring down the blood pressure) did
nothing to correct their basic problem.
These mothers usually gave birth to tiny, immature babies, half of whom were too weak from prolonged prenatal malnutrition
to survive being born. A large percentage of the survivors were left with lifelong disabilities such as mental retardation.
This brief encounter with the profound and stark realities of what poor nutrition meant to the lives of these mothers and
their families stayed with me for the rest of my medical school, internship, and residency years. In 1958 I began an ob/gyn
residency at the University of Miami, where Ferguson had become head of the department. My goal was to establish a research
basis for the connection between malnutrition and MTLP.
My work in the Contra Costa clinics took the ideas one step further: I wanted to organize a prenatal care service that would
have the patients' nutrition as a top priority, hoping to see a disappearance of MTLP as a result. This would not be an academic
setting for an experiment in which some women would be adequately fed according to a planned regimen and other left on poor
diets, or systematically denied nutrients, for the sake of "seeing what would happen." I had seen very clearly what would
happen during my medical training, and I was interested in truly preventing such tragic outcomes through nutritional counseling
methods alone. Several times during the course of the Contra Costa project, I was offered research funds with just that sort
of "control group" as a condition of receiving the grant. But, in good conscience, knowing what I did then about the consequences
of malnutrition in human pregnancy, I had to refuse such proposals. My single-minded, all-consuming drive was to get the
nutrition message home to every woman who came to our clinics for care so she would act on the information.
Knowing about it wasn't enough. Each mother had to carry through with the required diet every day, no matter what else happened
in her life, in order to obtain the benefits of sound nutrition for herself and her new child. And, as with any action program,
the day-to-day situations that sometimes stood in the way of the mothers being able to eat well enough for pregnancy. Over
the thirteen years of the project I also developed a set of key concepts in pregnancy nutrition--a set of principles that
guided me in counseling mothers and, ultimately, in training other young doctors who passed through the clinics as part of
their residency training programs. We have just completed a book [as pf 1983] detailing all these situations and how to handle
them, The Brewer Medical Diet for Normal and High-Risk Pregnancy (New York: Simon and Schuster, 1983), but we include
here a brief summary, to show how many ways your nutrition really does matter during pregnancy.
PNP (PREGNANCY NUTRITION PRINCIPLE) #1:
MOTHER AND BABY ARE ONE BIOLOGICAL UNIT.
WHATEVER AFFECTS ONE, AFFECTS THE OTHER.
NOURISHING THE MOTHER
IS THE ONLY WAY TO NOURISH THE BABY.
For years everyone thought the baby was a parasite, that it could extract nutrients from the mother's body irrespective of
what she ate, that it would be a certain length, weight, and degree of development at birth due to genetics or heredity--in
short, that the mother's diet had very little to do with the baby's growth in utero.
We now know, thanks to some brilliant work on placental function done in the early 1960s, that only nutrients actually present
in the mother's bloodstream are available to pass through the placenta to feed your baby during pregnancy. Furthermore, because
of increased metabolic demands of all sorts during this period, nutrients in the bloodstream are used up more quickly than
when you're not pregnant. So, you diet must provide all the necessary nutrients in larger amounts than before, and
you must eat more often to maintain blood levels at an optimal level. This translates into more food, more often--a
"grazing" plan that is especially important in the last weeks of pregnancy when you simply cannot sit down to a full-course
dinner and enjoy it because of your over-crowded abdomen.
This cookbook recognizes these needs and provides a daily, diet-planner chapter, complete with nutritious snack suggestions,
to help you make the change to this food pattern. Most women have little trouble during mid-pregnancy: their appetites tell
them that they need more food, anyway. Just keep in mind that there will never be another time in your life when making each
bite count nutritionally will be more important. Also, because of the fact that most substances cross the placental membrane
readily, this is a good time to avoid all substances that can reduce your desire for food. These include tobacco, alcoholic
beverages, additive-laden synthetic foods, street drugs, and over-the-counter drugs. Prescription drugs should also be avoided,
unless absolutely essential for the treatment of some major medical condition; even in this case, you'd be wise to check the
label on the drug and see what it says about use during pregnancy--I'm sorry to say that many of my colleagues prescribe,often
needlessly, a wide variety of drugs that are absolutely incompatible with a healthy pregnancy. The American Academy of Pediatrics
states that no drug has been proved absolutely safe for the unborn child (even those approved by the FDA). Since drug
compounds are carried by the bloodstream, they count as part of your total nutrition picture...and that of your unborn baby.
It is well established that the interconnections between nutrition, embryology, and pharmacology are extraordinarily complex.
A very thorough presentation of the current state of knowledge [as of 1983] regarding chemicals in our environment and their
effects on the unborn is Christopher Norwood's At Highest Risk, (New York: McGraw Hill, 1981).
Because your liver does its more efficient job of detoxifying your body of harmful substances when your diet is at its best,
a sound pregnancy nutrition program is your baby's strongest line of defense when you are inadvertently exposed to such agents.
For instance, even in areas where highly toxic chemicals have been used in defoliating large forested lands, not all pregnant
women exposed to the spray developed problems with their pregnancies. It may well be found after considerably more research
is done that the unaffected mothers' nutritional status proved to be the factor that protected their unborn babies.
In animal studies of drug side effects, the nutritional status of the experimental subjects is carefully recorded to control
for any potential contribution malnutrition might make to defective offspring. This assures the researchers that the side
effects they do discover can be attributed to the drug being tested. When the nutritional status of humans participating
in drug or other chemical research is similarly accounted for, we will have a much clearer idea of which substances are truly
troublemakers in pregnancy, and which of the adverse outcomes are related to undiagnosed poor nutrition. Failure to control
this criticl variable unfortunately holds much of today's research into these problems up to serious question.
Nowhere does this defect in contemporary research design appear more glaringly than in the enormous attention currently being
paid to the issues of smoking and alcohol ingestion by pregnant women. While we are absolutely in favor of pregnant women
(all women, for that matter) refraining from smoking because of the long-term health problems it causes (heart disease, emphysema,
lung, mouth, and bladder cancer), there is no sound research [as of 1983] proving that smoking causes low-birth-weight babies.
In fact, every experienced physician can cite case after case of mothers who have not been able to give up smoking and still
gave birth to eight- and nine-pound babies! If smoking is the crucial factor in low birthweight, as so many of the current
advisories from government and private health organizations proclaim, then every woman who smokes ought to have a baby weighing
less than five and a half pounds at birth. This is simply not the case. It may, however, be true that if the mothers who
smoked and had good-sized babies had not smoked, their babies might have weighed another four to eight ounces each
at birth. The narrowing of maternal blood vessels associated with smoking is well-documented, and it may contribute to a
certain reduction in birthweight. In an otherwise normal-sized infant, however, this small reduction appears to have no significance,
either at birth or later on.
Again, the design of smoking research has not included careful controls to establish the mothers' nutritional status. The
definitive answer will be forthcoming only when a group of smoking mothers is well-nourished according to a well-defined set
of clinical measures and their pregnancies and babies are compared at the end of the experiment with a second group of smoking
mothers whose nutritional needs have not been so well cared for.
It is widely known that when you stop smoking, your appetite picks up. After thirty years as an obstetrician it is my impression
that the major nutritional problem of pregnant women who smoke is that smoking replaces food for many of them. Smoking mothers
who eat well do not develop the range of pregnancy complications we see in smokers who do not eat well. But it's the nutrition,
not the smoking habit, that makes such a vast difference. The low-birthweight infants born to heavy smokers who do not eat
well are a result of the mother's malnutrition. If a mother's finances are tight, money spent on cigarettes is just that
much less she has to spend on good food--another reason why smoking contributes to poor nutrition for so many people. These,
of course, are not direct effects of the smoke itself entering the body, but in our view they are far more significant in
terms of harming a mother's nutritional status during pregnancy.
The alcohol research follows along the same lines. It is inappropriate to alarm every woman who enjoys a glass of wine with
dinner about the risks of fetal alcohol syndrome, a problem in babies born to chronic alcoholics--a group of women known to
be profoundly malnourished even before they become pregnant. If one or two glasses of wine or beer, or a single cocktail,
were enough to cause problems in the newborn, surely all of Europe would have been depopulated long ago! By no means do I
want to encourage the consumption of alcohol, but it is clear that the well-nourished mother easily metabolizes small amounts
of alcohol taken along with food, whereas her poorly nourished neighbor, who obtains most of her calories from alcohol and
is deficient in almost all other essential nutrients because she rarely eats a meal, is not going to withstand the nutritional
stress of pregnancy, nor is her unborn baby going to develop normally. Our advice is to refrain from alcohol consumption
if it makes you dizzy or bothers your digestive system. Otherwise, limit yourself to no more than two ounces a day, always
with a meal.
Caffeine presents another consideration: it is a stimulant. As a result, beverages containing caffeine not only take up space
in your diet that might better be given over to more nutritious foods, the caffeine itself revs up your nervous system so
you feel bouncy and full of pep even though you haven't obtained all the nutrients you need. Small wonder that test results
show a higher proportion of birth defects and prematurity in studies where mothers consumed more than eight cups of caffeine-containing
beverages (coffee, tea, colas) a day. Remember, that's a half gallon a day--a large percentage of your stomach capacity--taken
up by no-nutrient beverages. There may be some women who do this out of habit while working, but their numbers aren't that
many. If you absolutely can't face the day without your morning coffee, so be it. But for the rest of the day, drink milk,
real fruit juices, or an occasional mild herbal tea. You may experience caffeine withdrawal (headaches, lethargy, jitters)
for a few days, but once you're weaned from it, you'll appreciate your calmer disposition and your improved ability to sleep--another
important part of your complete pregnancy care program.
PNP (PREGNANCY NUTRITION PRINCIPLE) #2:
A LITTLE MALNUTRITION IS A DANGEROUS THING.
PREGNANCY IMPOSES A NUTRITIONAL STRESS ON EVERY EXPECTANT MOTHER.
THIS STRESS INCREASES AS PREGNANCY ADVANCES TO TERM.
It's been known for several decades [as of 1983] that the baby's organs develop in the first three months of pregnancy. The
heart, for instance, starts beating by the twelfth day after the embryo implants in the mother's uterus. Arms, legs, eyes,
lungs, digestive system--all are present by the twelfth week. But recent research on the brain [as of 1983] presents a different
story. Though some parts of it exist by the end of three months, there are two periods of rapid growth later in pregnancy;
one beginning at the fifth month, and the second beginning one month before birth. These growth spurts are essential to the
normal formation of brain cells and their organization into systems that can process information and regulate responses to
stimuli.
Dr. John Dobbing, a British expert on the brain, writes that even mild degrees of undernutrition during these critical phases
of brain development can interfere with optimal growth and function later on in life. In other words, if your diet doesn't
meet the needs of your pregnancy, your baby is far more likely to have difficulty learning in school, swinging a baseball
bat, or enjoying other activities that require muscular coordination. Some people studying the phenomena surrounding sudden
infant death syndrome (SIDS) also wonder whether maternal undernutrition might adversely affect the portion of the brain that
regulates the baby's breathing mechanism so that, on occasion, the baby "forgets" to breathe for prolonged intervals. Without
resorting to speculation, though, it's been well-documented that smaller babies have fewer brain cells with less information-carrying
potential. The simple way to prevent most of this type of brain damage is to feed your baby well before it's born--and that
means feeding yourself well every day until you go into labor.
In addition to the pattern of brain development there are several other reasons why pregnancy causes a nutritional stress.
These factors are related to the internal changes that take place in your body to support a healthy pregnancy. The blood
volume, that is, the actual amount of blood circulating in your blood vessels, must increase dramatically to service the increased
demands of the placenta, an organ you did not have to perfuse when you weren't pregnant. If the placenta doesn't have adequate
blood circulating through it, it doesn't grow as large as it should, it doesn't transfer nutrients and waste products between
mother and baby as it should, and it doesn't adhere well to the surface of the uterus as it should--making it more likely
to shear off before the baby is born. All of these placental problems threaten the continuance of your pregnancy and, because
over a given period of time your baby receives fewer nutrients due to the reduced blood flow through the placenta, they also
threaten your baby's well-being.
Unfortunately, your blood volume doesn't expand automatically when you become pregnant. Blood volume expansion is a direct
response of your body, chiefly determined by the liver, to the quality of your daily diet. Not enough protein, calories,
vitamins, minerals (including salt) or water and the blood volume fails to expand, the placenta isn't perfused very well,
the baby grows slowly or not at all, and all your other organs also suffer from a reduction in blood flow. For many years
women were advised to restrict their food intakes in order to stay on a weight gain chart that gradually reached a peak of
twenty-four pounds at the end of pregnancy. Today, we know that this approach to pregnancy nutrition can thwart the necessary
blood volume expansion for a healthy pregnancy and place mother and baby at higher risk for complications. Instead, progressive
midwives and doctors these days are encouraging their patients to eat to appetite from a diet list of highly nutritious foods
in order to insure that the blood volume expands to the fifty to sixty per cent above pre-pregnancy level that correlates
with best outcomes for mothers and babies. The shift in emphasis means that mothers should be spending far less time worrying
about the numbers of pounds that show up on their scales; that time is better spent filling in diet checksheets to make sure
you've eaten a complete diet every day. The following chapter provides all the forms you need to do just that.
PNP (PREGNANCY NUTRITION PRINCIPLE) #3:
MANY LIFE SITUATIONS
CAN CREATE NUTRITIONAL PROBLEMS.
IDENTIFY THEM AND MAKE DIETARY CHANGES AS NEEDED
TO PROTECT THE NECESSARY SUPPLY OF NUTRIENTS
FOR YOUR PREGNANCY
When people are under stress, they often don't eat regularly or they may not feel like eating the foods they need. Pregnancy
itself can provoke stress within families and events unrelated to a woman's pregnancy can have great impact upon it, such
as the illness of a parent or child, loss of one's job, or abandonment of the pregnant woman by her mate. Also, an expectant
mother can become ill with any disease that affects the non-pregnant population, often with damaging results toher nutritional
status. Some of the most common situations that wave the red flag of possible undernutrition to me:
Using these fundamentals, counseling my patients at every prenatal appointment, making sure each woman understood her diet,
trying to catch early any problems each might be having in following the diet--these all paid off. In our clinics, according
to data from the National Institute of Health, which spent three years collecting information from our 1965-1970 prenatal
charts and another five years analyzing it, there was not one case of eclampsia in over five thousand pregnancies,
and mild MTLP fell to less than one per cent in mothers having their first babies (traditionally viewed as those at greatest
risk of developing the disease). Other public clinics report anywhere from fifteen to forty per cent of their first pregnancies
complicated by MTLP. Furthermore, women in our program were ten times less likely to develop hypertension (high blood pressure)
in pregnancy, a problem that can occur separately or as part of the symptoms of MTLP. Finally, the incidence of low birth
weight (five-and-a-half pounds or less at birth) dropped to 2.2 per cent overall and 2.8 per cent in first-time mothers, as
compared to another clinic serving the same population but not using these nutrition methods where the rate stayed at 13.8
per cent. I was gratified to have NIH confirmation of our approach, but not surprised by it, since this was the correct way
to conduct prenatal care if we were seriously interested in producing the healthiest possible babies and mothers.
The success of your pregnancy is largely in your own hands. I hope this cookbook will help you to have an enjoyable, problem-free,
and rewarding experience.
Eating for Two (by Gail Brewer and Isaac Cronin) available here...
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