Gestational Nutrition and the Family Stone

Leslie P. Stone, MD, IFM-CP, is board certified in family practice with a fellowship in surgical obstetrics. She is an international lecturer on developmental programming of disease and application of individualized functional medicine care during pregnancy. Her passion is helping parents capture the miracles during pregnancy by changing habits and their lives, and empowering life in and out of the womb. She is the primary consultant for GrowBabyHealth.com, an individualized nutrition-and-lifestyle program promoting generational health. She is owner of Ashland Comprehensive Family Medicine-Stone Medical in Ashland, Oregon, where she continues to practice. Her ongoing clinical research centers on aspects of the developmental programming of health, a functional medicine approach to pregnancy, and comparing birth practices, including vaginal births after cesarean and water births with other birthing experiences.

P. Michael Stone, MD, MS, IFM-CP, is the medical director of Ashland Comprehensive Family Medicine, a 9-clinician, functional-medicine, primary-care, insurance-based clinic in Ashland, Oregon. He lectures internationally on wide-ranging topics including 1-carbon metabolism, nutrition adequacy and inadequacy, the nutrition physical exam, and developmental programing of health and disease. He is on the Institute for Functional Medicine faculty and consultant to Tallahassee Family Medicine Residency and Florida State University on functional medicine. He cooperated with Emily Rydbom, CNC, CNP, CHN, and Leslie Stone, MD, IFM-CP, in the development of the GrowBabyHealth.com program to help couples create a foundation of health for their families during pregnancy, when there is the greatest opportunity for change.

Emily Rydbom, BA, CNC, CNP, CHN, is the owner of GrowBaby, and mother of 2. She has been practicing a functional nutrition approach to pregnancy for more than 5 years. She has an active clinical practice within Ashland Comprehensive Family Medicine in Ashland, Oregon, helping women reach their nutrition and pregnancy health goals. Her passions include empowering women during the preconception, pregnancy, and postnatal time period, and teaching families about healthy nutrition and lifestyle balance from 6 months to beyond 5 years.

Integrative Medicine: A Clinician’s Journal (IMCJ): Leslie and Michael, what originally got you interested in pursuing nutritional therapies to influence gestational issues and maybe even disease beyond the womb?

Leslie: I have been trained in obstetrics initially and then stopped and went into family practice and followed up with a high-risk obstetrics fellowship. By the second decade into this, I became alarmed to recognize that rates of really common problems in pregnancy that influence the health of neonates were not improving. If anything, they were getting worse, even compared with other industrialized nations. These include our increasing rates of miscarriages and infertility. Despite all our great technologies, these were not improving in our supposedly “excellent” medical model.

Functional medicine is where people think in a very 3- or 4-dimensional manner about all of the factors that influence the expression of disease or health, and when applied to pregnancy—it means we are going to think about all the events that happen during prepregnancy, during pregnancy, and in that F1 generation. The early years, even up to 4 years, highly impact the trajectory of health in the F1 population as an adult, particularly in terms of the incidence of chronic diseases. Those run the gamut: cardiovascular disease, obesity, diabetes, neurodegenerative disorders, psychoneurologic disorders, and immune disorders. And then, lo and behold, it looks like its effects reach through to the following generations.

We have strong evidence for F1 and F2—first and second filial—generations’ effects in the human population, and we have further generations in animal populations with shorter gestational length. We realized, as we were looking at our 1-patient population, that what was happening to them in a nutritional and lifestyle manner was significantly impacting their rates of maternal diseases and their rates of adverse neonatal outcomes. The problem was finding a way to impact that. Is there a way to make this change in a positive manner? We realized through the emergence of developmental programming that yes, there are nutrient factors, there are dietary factors, and there are stress management factors that really do change some significant pieces of maternal health. The ones we have focused on are diabetes in pregnant women, hypertension and preeclampsia/eclampsia in pregnant women, and any problems within the maternal environment that affect the size of the baby at birth.¹

It turns out that the size of the baby at either end of the spectrum turns out to be the biggest predictor of who is going to be at risk for these disease outcomes in children, adolescents, and adults. We have found within our population some significant nutritional deficiencies—both micro- and macronutrients—that, when addressed within the prenatal and perinatal time period—we reduced our rates of these adverse outcomes for the neonates and for the mother. It’s been an exciting journey, but it’s taken us about 30-plus years to get there, I would say.

Michael: Leslie and I both went into family practice so we could deliver babies. Between us, we have delivered somewhere around 5500 or 6000 kids. Now, the other interesting thing is that my undergraduate and graduate degrees were in nutrition prior to medical school. This was in the early days of vitamin D recognition and knowing the effect of too much or too little on the fetus. As Women, Infants, and Children, or WIC, program volunteers in undergraduate and graduate school, we saw the effects of nutrition on the mom during pregnancy, especially in immigrant populations.

Then we spent some time on the Thai-Burma border, where Leslie can recall how people change their diet to limit the size of the baby to make their delivery easier. This is all in the mix with our rural practice of medicine in primary care where we watched multiple generations. We knew multiple generations in rural Idaho and rural Oregon and different parts of the world. You see patterns if you have the eyes to see, and you see persistent issues if you have eyes to see.

In 1998, when we started looking through the lens of functional medicine and all things chronic, we found ourselves asking a lot of questions. One of the people who prompted us to ask more questions was David Barker, MD, PhD, FRS, from England and eventually out of Oregon Health Sciences University. One of his areas of research focus was in eastern Oregon and specifically on the effects of nutrition and the intrauterine environment— on the development of cardiovascular disease.

It all started coming to a head for us when we started seeing more of the data coming out on the transgenerational effect of the intrauterine environment and nutrition on the offspring—and not only the offspring but on the offspring’s children. That was further strengthened by the Dutch famine studies and the Chinese famine studies out of the World War II era. For the Dutch famine studies, and depending on which trimester they were calorically restricted, it changed the pattern of disease in the offspring.² In studies of the Chinese famine in the late 1950s and early 1960s, it showed the effect of famine on not only the incidence of blood pressure but also heart disease.³ The Gambia study showed that when you conceived—during the dry season or during the wet season—changed how DNA was marked or methylated differently in the offspring specifically related to availability of methylation factors and balance changes induced by food availability during the normal cyclic seasons. Suddenly, there was the connection between the intrauterine environment and how the DNA was marked, revealing an epigenetic mechanism that permanently altered the plasticity effecting growth and health.⁴ Now 6 years ago, an early epidemiology study out of University of California, Davis showed that if the mother had common single nucleotide polymorphisms and the baby had certain common single nucleotide polymorphisms and the mother did not have enough of the B-vitamin methylation factors 3 months before conception and 1 month after conception, there is a 720% increase relative risk of autism.⁵ This confluence of information was the basis of our urgency to help get this information to our patients and our communities.

We have 4 children. Emily is a clinical nutritionist, another daughter is in nursing school, a son is in medical school, and another son is a biostatistician. As a family, we got together and, with this urgency, asked how we could bring a program forward that educated the mother on the 3 different trimesters and the different nutrients that are so pivotal in so many aspects of fetal development. This effort to try to impact generational health led to Emily and Leslie—and me more as a literature evaluator and kibitzer—developing a program that has impacted and changed the course of conception, successful pregnancy, and outcomes in our clinic. The program’s reach now extends beyond our clinic through what Emily has done using Internet platforms.

IMCJ: Emily, what is your perspective of this process?

Emily: I have been fortunate to grow up in this culture of thinking, so when we rattle off the multitude and depth of information, having listened to it my whole life, it is easier for me to digest. What I quickly realized in a clinical practice was that it became overwhelming and disempowering for patients, when it was meant to the be opposite. I felt an enormous responsibility on my end to be able to give them enough information in a way that they could take control of their own health, with myself, Leslie, and Michael as the scientific guide in the background.

I quickly realized that I had to create a nutritional platform that disseminated the information in a shopping-list way, so that the clients—the women and the couples— did not see all of the effort in the background. Our food plans were created based on the gestational needs of a developing fetus, the most nutrient-dense foods and where to find them, and the best ratio to eat these macronutrients. We simply handed them a food plan. We figured out what they needed in terms of fuel, but what they did not know was that it was based on 30 years of clinical research and 4 years of concentrated research review, and then from there it has blossomed into kind of a biopsychosocial approach to the pregnancy time period. My job is to be the translator of that.

Michael: Leslie and all 4 of our children were very accomplished athletes. They coached. What is interesting is to see the translation of coaching for success that athletes learn. Emily would frequently look at me and say, “Papa, there’s too much information. Don’t be a drill killer. You want this to be a drill that actually works and empowers and improves skill. Don’t give so much that they’re frozen.” I think that from a functional medicine perspective, the key is determining what the one thing or the bite-sized piece is that will help people move on. We have a functional medicine timeline, but it is interesting to think of the parallel functional medicine timeline for the 1 or 2 or 3 unique people in the womb. It causes a different shift and a different urgency because it is a very finite time for you to impact change. There is no greater time, it seems, in our experience, for anybody to change than when a mother is carrying a child or a father becomes willing to change because he wants to help the outcome of the pregnancy.

IMCJ: So when was it that you decided to bring the family together and create this plan?

Leslie: We, first of all, started recognizing the role of micro- and macronutrients in producing this health trajectory, and then we went about testing our theory, and that was in about 2011. Then we thought, “Let’s take a look at our patients who are fairly middle class, fairly run-of-the-mill socioeconomically. They should have access to adequate nutrition and adequate lifestyle measures.” I thought, “Let’s pick out these nutrients that we realize are the key factors, cofactors, and the enzymatic activities that are necessary for healthy pregnancies and healthy outcomes and look to see if they are deficient.” We found that 65% of our population were insufficient in some way by the time they hit the third trimester. Ninety-plus percent of our population was carnitine deficient. Iron deficiency was in the 40% range, and 70% for vitamin D in our latitudes. Ninety percent of these counted as insufficiencies. Our protein content was phenomenally inadequate. It was alarming. So we decided to see if we could make a difference if we systematically reviewed particular risk factors, particular triggers, and particular antecedents. We applied this functionally to see what kind of outcomes we obtained. That initial approach became what we do with everybody within our clinic. I think 2011 was the first consistent year, and then we pulled data for 2 years consistently and came up with our remarkable result that we published.

Michael: I think it was brewing for a long time. We both grew up in a small, rural migrant community. Early in high school and college, I would go with our primary care physician or our family doctor to do migrant camp visits because he would volunteer his time to do that. He would see different patterns. Then in Thailand, when were there in 1983, I did a nutritional assessment of 250 orphanage kids and saw patterns of sufficiency and deficiency.⁶ The nutritional component has always been there. As a family doc, when you start seeing patterns of food consumption and patterns of adequacy in the families that you become pretty close to and aware of in small communities of 2000 or 5000 when you are working, the questions keep bubbling up concerning adequacy.

Then when you see changes in certain families that are epigenetic in nature that occur from stress or food or environmental factors that impact the development of that child, all these things percolate in the eyes of clinicians who are connected to their population. It really coalesced in the early 2000s when papers showed how within 20 minutes of consuming different combinations of essential fats versus saturated fats you turn on or off the genes that inhibit inflammation. Suddenly, that combined with the autism occurrence study—the urgency of affecting what is in each bite. The focus changed from nutrition for a lifetime to how you can turn on and off genes quickly by changing what somebody puts in their mouth and consumes—changing their microbiome and all the different things we think about in functional medicine. It was like taking a dimmer switch and turning it higher and higher and putting more light on the subject.

That is the confluence of understanding and papers, whether it was from Bruce Ames and the triage theory, or the ideas that were brought out by the many different speakers in functional medicine. These kept washing over our perspective and kept washing over our family and kept washing over our patients. We needed to coalesce something, and that is what has happened.

IMCJ: Where did you start with your interventions? When did you start to feel like you were on to something?

Michael: I think it was vitamin D.

Leslie: The one in which I could see the best expression and the quickest reward was actually carnitine.

Michael: Yes, yes.

Leslie: We started with looking at carnitine insufficiency as being another reason for fatigue in a nonpregnant population. Michael, going after it mechanistically as he typically does, said, “Did you know that carnitine is a required dipeptide for transporting fatty acids in the mitochondria—the carnitine shuttle—and thus resulting in more energy production by helping the harvesting of energy from the fatty acids?” I said, “No, I didn’t know that. Let’s try carnitine with our adult fatigue patients who I can’t find any other reason for it.” Again, we functionally evaluated these patients and just came up with looking at another pivotal nutrient.

Then we looked at carnitine and, sure enough, everybody who was deficient did better with supplementation or the nutrient or with high-carnitine foods. Then I thought, “My goodness, a lot of my pregnant patients also complain of fatigue, but of course they should because they’re pregnant.” But then we have females who said, “No, no, no. I am particularly fatigued.” So I would check their carnitine level, and they would be deficient. Then I would give them carnitine and within a day or two they would say, “Wow, I feel so much better.” It was that fast. Then I thought, “Maybe I should check all the patients for carnitine.” Sure enough, those who were deficient all felt better—and they were pretty much all deficient. Carnitine, the carnitine shuttle, and being able to get free fatty acids into the mitochondria for the improvement of ATP production from their dietary fats … a key in our fatigued patients.

It also became obvious, looking at this mechanistically, that the accumulation of fatty acids in the cytosol also leads to all sorts of inflammatory proteins that are consistent with increased risk for diabetes, be it gestational or otherwise. There are a few studies out there showing that in carnitine deficiency, working toward carnitine sufficiency both through increasing protein calories as well as direct supplementation reduces these markers of inflammation and women are less likely to become gestationally diabetic.^7,8 For those patients who do not become diabetic, their kids are less likely to become diabetic as adults—a direct correlation. That was the first step that made us decide to look for other known micronutrients and well as macronutrients that can affect this trajectory of health, and we started analyzing.

Michael: We started checking vitamin-D levels because of the local latitude and its association with some adverse effects in pregnancy and in the offspring when there is deficiency. We started checking that in 2004 after seeing the work of Michael Holick, MD, PhD. Except for a short stint in Ventura, California, we have always lived above the 37th parallel, and so our populations have really low vitamin-D levels. We noted in the early 2000s that a lot of our patients were vitamin-D deficient. We started addressing that and saw pain syndromes improve, we saw change in fibromyalgia, we saw change in respiratory tract infections, and we saw some change in allergy. Then we started, because of family issues really, bringing in MTHFR components and looking at the methylated factors. We initially started looking at the couple of the snips for folic acid.

We found that 35% of our population had either heterozygous or homozygous recessive combinations for a couple of common folate single nucleotide polymorphisms, or SNPs. We know that has always been an issue with pregnancy because of the association of low folate levels in neural tube defects. Then we started looking at the number of our patients who are homozygous recessive, which by definition indicates a double requirement for folates because they do not activate folates to methylfolate with the same efficiency for the carbon metabolism.

We did a small in-clinic study looking at 300 people. Our children were very involved in harvesting data during their college careers because we could pay them hourly to help do chart review. We checked the genetic SNPs, and we looked at their medical symptom questionnaires. After 300 chart reviews in our clinic for people who were homozygous recessive or heterozygous for MTHFR 677 or 1298 SNPs, we found that one of the early symptoms was alteration in consistency with menstrual periods and amenorrhea, which was followed by depression and sleep irregularities.

Then, we started augmenting that knowledge. We knew our patients were frequently low in magnesium and their essential fatty acid levels were going to be low. We could tell by their diet once we added a nutritionist to our clinic—now 10 years ago. In a survey of the first 100 charts of patients who were seen by the nutritionist, there were 63 patients who had eating disorders that had never appeared in their chart before. Suddenly, the nutrition professional in our clinic was uncovering all this disordered eating that would not necessarily show up in their wide ranging lab results or in the compiled medical record in this 30-year-old clinic. But by the Ames triage theory, instead of looking at just one thing, we started considering bundles of macronutrients or bundles of micronutrients or cofactors that changed the way we looked at an outcome.

Leslie: We had been trying a few smatterings of things to reduce these maternal morbidities, and none of them worked. I could tell after a year or two or three of ventures into magnesium alone or magnesium and vitamin C alone or those sorts of things without really enlarging the context. Even beyond the nutrient piece of this, it is also the stressors, it is also the sleep, it is also the exercise—all of these pieces impact the metabolism.

Michael: One of the challenges is I was looking at individual nutrients as many nutrient researchers do and not looking at food. I would say that a powerful aspect of adding Emily and our changing perspective is that we devised what we considered a great prenatal supplement combination for our population. But the empowering thing was using supplements only as a bridge. What our program does is recognize that there is no supplement that you can put together that comes anywhere close to being a substitute for the right perspective on food eating. That both empowers the woman with her pregnancy and her health and empowers the couple in health for their family. The food message, whether you are on the women and children nutrition program or no matter what the community, is encouraging healthy eating and approaching all the connections that we have with our food in a healthy way. That really empowers and offers hope.

Leslie: The other powerful motivator for us is the global epidemics of chronic disease. Coming back and trying to figure out if there is anything that we can do at any point of the life cycle that is going to impact the trajectory toward death. Our generations are not, at this point, looking like they will live as long as the earlier generation. We have globalized our standard American diet, and associated with that is the globalization of disease. That has been a powerful motivator for us to look at where the most plastic, the most manipulatable, the most likely opportunities to exert powerful changes may be and learn how to make them happen. This is that time period, that perinatal time period through about 4 years of age.

Michael: When you start looking at development origins of cardiometabolic disease and you look at the different conditions that set up inflammation, and then when you look at obesity in our society and maternal obesity, it is no longer an issue of looking at calories. It is looking at what are the triggers of obesity, those antibiotic triggers, the heavy-metal triggers, and the different toxicity triggers. Their toxicity is bioconcentrated in the offspring, in the fetus.

Leslie: These are perinatal toxicities, including stressors.

Michael: You impact the hormone cascade and cycles in the fetus’s brain during pregnancy depending on the stresses of the mother. Through a functional medicine lens, the maternal diet can help the mother and the fetus get rid of toxins. And when you start looking at the phenomenal impact of everything from maternal gum disease or tooth disease on bacteria levels in the womb by the second trimester, you recognize it is affecting the health of the infant and changing their own inflammatory response. If you look at a mother who eats more fruits and vegetables in the second and third trimester, it impacts what the baby’s preferences are; ie, to eat more fruits and vegetables.⁹

In the offspring, you recognize that if we can empower the mother to change her perspective of food and the healthfulness of food and nutrients, it totally changes disease literally from what the baby is willing to taste to what is happening by the time they’re 18- or 19-year-olds with incidence of renal disease, hypertension, and heart disease. There are many days that we feel phenomenal urgency about this.

IMCJ: Looking at the evolution of research around mitochondria and the fact that mitochondria are completely inherited from the mother, how does that affect your nutritional approach to perinatal and prenatal nutrition?

Leslie: That is a fact. I do not think that I can change that maternal mitochondrial DNA transfer, but there are things we can do, of course, to affect how much transcription is taking place of that mitochondrial DNA with different epigenetic mechanisms. We can open and close the chromatin on that DNA by addressing a variety of different stressors, nutrients, and interventions. By this exploration, we recognize how impactful it is that people have … For example, that autism study that Michael quoted earlier: These are inherited tendencies that people have. They have a gene variance that based on a cluster of gene variance, not just 1—but a cluster of them.

We’ll use autism as an example. If we put that person, that mother, into a B-vitamin deficient state, that impacts the expression and transcription of DNA on an already vulnerable gene variant. The result is remarkably, frighteningly increased rates of autism in vulnerable-gene-variant-susceptible offspring as well. In addition, if they are already vulnerable based on their gene variance—this has to do with methylation again—then if we don’t follow up with that baby, if we do not recognize that vulnerability, then we know that those persons will have the phenotypic expression of autism in their life. The good news is that we are beginning to recognize those pieces. We can intervene appropriately. We can assist, and we can alter the activities of those different genes. We are learning more and more about them every day.

Michael: You get some hints of that from studies like the Gambia study where they look at methylation markers on the DNA of the offspring, whether there was nutrient adequacy and inadequacy at different points of the pregnancy.

Emily: When thinking about mitochondria function, I think of energy production. We address the nutrient needs of our cells to improve energy output first through food. Those cofactors can be varied for each individual, but at the end of the day, they are a specific set of nutrients. This is what I love about our bodies; once you recognize the cofactors you can be succinct and direct.

Michael: At the presentation discussions a couple of years ago at the Institute for Functional Medicine annual conference, Randy Jirtle, PhD, presented and Leslie and I both spoke. In our conversations with him afterwards, he was excited to see the case presentations with background that Leslie did. He said, “You know, what we need to do now is evaluate the imprintome of the offspring,” meaning that we are starting to be able to map the changes that are passed on from mother to child—imprinted on the child—with the epigenetic influences of changing behavior, nutrition and food in the womb, changing stress in the womb, and changing hope and empowerment in the womb. That becomes part of the imprintome that can be followed in the offspring and is getting really granular, but that is really where this is going.

One other aspect that I’ll mention about food is we know that we are getting micro-RNA from plants when we eat plants or fruit, or micro-RNA from animal protein and from grain proteins. We are getting micro-RNA from each bite. This micro-RNA interacts intricately with our system and can promote disease or promote health. I think that is where the next frontier is for understanding some of the chronic illnesses. It is not about a supplement pill. It is about what the food components are and what the functional nutrition components of food are, particularly where you are getting cross-kingdom influences from the plant kingdom to our kingdom. These food components will influence what pathways are turned on and turned off in our system. Through a functional medicine lens, we are trying to open the accordion of understanding even further and enhancing the health and empowerment of the mother during pregnancy and the family during growth and trying to diminish disease occurrence.

IMCJ: Emily, when you sat down to fit all this together, what kind of challenges did you face while trying to make the whole food pieces and fit the changing nutritional needs of the mother throughout the whole process of gestation and birth?

Emily: Well, I started with a low-glycemic index base. I took all the foods that fell into what we know in current research to be one of the most effective ways, nutritionally, to help manage what we are seeing as manifestations of cardiometabolic disease globally. With that as a base and the help of Leslie and Michael and our research together identifying the nutrient cofactors that are going to optimize the health and gestational development per trimester, I then found the most nutrient-dense foods for each of those trimesters—including the fourth trimester time period—12 weeks postpartum. I then looked into the most common diagnoses of pregnancy such as gestational diabetes, pregnancy-induced hypertension, preeclampsia, and what we now know as a very common genetic variant of the MTHFR expression. I extrapolated the most effective nutrients across those timelines and highlighted and bolded those food choices on every woman’s food plan.

We worked up from there, also recognizing the power and I think the underutilization of nutrient density and complexity of palate creation found in herbs and spices in the kitchen. They have a role as dense antioxidants and anti-inflammatory choices without selecting voluminous food amounts.

Emily: The food plans are single-page documents. There are 11 different food plans, and each one is a single page, making them digestible. It started out as 3 pages of food with cross-referencing, bullet points, highlighting, and cross-outs. It was an impossibility for people to try to consume.

Because we recognize that socioeconomic middle-class folks have access to so much of what we are speaking about, whereas there are deplorable rates of adverse maternal and fetal health outcomes in the lower socioeconomic and poverty-stricken demographics, which more often includes the WIC folks who have access only to government subsidies. I also converted this nutriture into what a woman participating in WIC purchase and how those foods fit into her pregnancy timeline. I felt some urgency in the need for that translation, and this is a universal approach. Everybody has access to it; everyone can do it. We were consciously trying not to exclude any single demographic while empowering them where they are at.

IMCJ: Some of that speaks to compliance. I am guessing from what I am hearing that, initially, compliance was a challenge.

Leslie: It was.

John: Then you have seen improvements as you have progressed?

Emily: Yes. What has come from that are multiple ways to access this information with constant reinforcement, not only from Leslie or myself directly, but also through various educational channels. There are 4 different classes for each trimester. Each is 60 to 90 minutes of teaching and then at least 30 minutes of question and answer in a group setting, because we find that group learning increases compliance, increases health goal attainment, and also improves the social health of the female during pregnancy as well. But we needed to find a way to disseminate this information on a larger scale and so now offer 2 different versions of online platforms for access. One is a recorded version of our classes and an e-learning module, where you have an interactive e-learning experience for 20 minutes.

The disadvantage of recorded classes and e-interactive learning is that they are not as readily adapted to the most current science and research. So, we also offer these courses live online. We have online communities of women going through flights of classes together, and then they create their own group experience while I facilitate it. They work with one another through the information and this like-minded approach.

Emily: We also have an app. It is a digital food journal called GrowBaby Mom—a direct consumer app. We also have GrowBaby Pro for a practitioner who would love to have access to a nutrition professional or registered dietician but cannot for whatever reason. This app is modifiable by trimester, by how many babies the mother is having, and by their gestational age. It provides suggestions for healthy weight gain based on their prepregnancy BMI and their activity level, as well as being modifiable to the top 10 most common food allergies in the United States and also the most common diagnoses of pregnancy: gestational diabetes, pregnancy-induced hypertension, and MTHFR. There is also a filter for preconception, and one for what we call body after baby. It helps a mom to gently approach her new maternal body—not getting it back, I don’t like that concept, I think it should be called moving your body forward—in a healthy way and get themselves into what they feel is comfortable.

Then this is all reinforced through our extremely robust social media campaign. We reach anywhere from 100 000 to 300 000 followers in any given week. We have active followers at more than 91 000 people. The message is resounding. What Leslie and Michael and I decided is that we try to focus on empowerment. If you Google pregnancy, there are at least 12 lists of things that you can’t do, can’t touch, can’t eat, can’t think about. We have tried to shift that message out of our amygdala—fear—and into an empowering concept: “This is everything you can do. Look at what is available to you to impact your health, your child’s health, and the generational health of your family.” We distill that message down into, “In your own very personal way you are changing the world. You are changing global health epidemic by what you choose to do now.” That’s reinforced in many ways, in many iterations, and as often loudly as possible.

IMCJ: Would you summarize some of the major deficiencies that pop up as gestation evolves?

Leslie: We take a standardized approach to pregnancy, plus, the earlier we have somebody, the better we can do. We check the normal infectious disease panel with everybody. We check the normal complete blood count, or CBC, but then we also add zinc, carnitine, vitamin D, and a couple of methylation genetic polymorphisms, and we make a few assumptions about epidemiologically consistently low magnesium and fatty-acid deficiencies. We take a robust history—even back through their birth history and their family history—to know what we are likely trying to prevent in them that had to do with that trajectory of health that we talked about.

Then we systematically go about educating them about how to do this in a whole foods, whole life sort of way. We adjust that nutritional approach and lifestyle approach per trimester. We repeat those values again at the beginning of the second to third trimester. At the end of the second and the beginning of the third trimester, we readjust our approach at that time. Then we consistently follow them through into the breastfeeding time period, adjusting again for those additional needs. The next adjustment occurs at 6 months for an introduction of foods to the young baby, and then one more time when it the child is eating the same food as the family, as it is incorporated into the family units eating culture and habits.

Michael: If the couple comes in preconception, we also address the father’s nutrient insufficiencies and look at his diet and family history because the father’s DNA markers and issues that are passed on via the sperm are the genetics of the placenta. If the father has certain genetic tendencies that require more different nutrients, the placental DNA and the nutrient transport across that placenta of different nutrients or different reactions are influenced by the father.

Emily: The father who has a low-protein diet, preconception, affects the reproductive health of their son, for example. So addressing those deficiencies early is really important.¹⁰

Michael: It is really important. We are finding that this plays a huge role in people who come to us with infertility or with multiple miscarriages, and then you address the father’s and the mother’s genetics and relative nutrient requirements. Then there is greater success in successfully conceiving and carrying a child to term. Only 9% to 11% of any conception gets past the early blastocyst stage all the way to a term delivery, and that means that there has to be an optimization of environment from both the paternal aspect that is soon to become the placenta and the maternal environment.

Emily: The first trimester nutriture for the mother very much, in terms of food, focuses on the support of organogenesis and which nutrients and cofactors are needed.

Leslie: Differentiation.

Emily: Right. And then continues into also supporting the developing thyroid of the child. Then in the second trimester it moves on to the myriad of nutrients needed for bone health as well as the beginnings of that idea of palate development. Maternally, the focus becomes continuation of the support for doubling blood volume and the energy requirement and output required and how to support that. Then third trimester nutriture focuses on the fetus brain gain and we ensure that we are addressing cofactors for the central nervous system.

Specifically, we look at nutrient cofactors to help the mother address her stress response in the second and third trimester, as we are learning more and more about maternal stress response concentrated in the second and third trimester and the epigenetic effect that stress response has on the developing fetus. From what we are seeing, these effects reach into the teen years.

Leslie: Maybe even beyond.

Emily: Right, maybe even beyond. Postpartum focuses on how to support the breastfeeding mother and the nutrient cofactors that are needed for breastfeeding, but we do have a very large emphasis on labor and delivery preparation, too. We address probiotics, decreasing the risk of group B strep, and how to do that with nutriture. Then in the fourth trimester, it is hormone rebalance, breastfeeding, what to do if you can’t breastfeed, and how to decrease the risk of mastitis with very specific probiotic strains, and maternal mental wellness.

Michael: What is interesting is you go beyond the baby. A healthy baby is great, but how does a healthy baby impact the health system? Well, a simple study out of Kansus University was just published this last year.¹¹ The Kansas University DHA Outcomes Study, or KUDOS, found a significant reduction in early preterm births with a supplement of 600 mg DHA per day compared with placebo. The objective of this analysis was to determine if hospital costs differed between groups. We applied a post hoc cost analysis of the delivery hospitalization and all hospitalizations in the following year to 197 mother-infant dyads who delivered at Kansas University Hospital. Hospital cost saving of DHA supplementation amounted to $1678 per infant. Even after adjusting for the estimated cost of providing 600 mg DHA per day for 26 weeks— $166.48—and a slightly higher maternal care cost—$26— in the DHA group, the net saving per dyad was $1484. Extrapolating this to the nearly 4 million US deliveries per year suggests universal supplementation with 600 mg/d during the last 2 trimesters of pregnancy could save the US health care system up to $6 billion.

When you look at a cost to a health system—saving costs by adding—and looking through the lens of functional nutrition as it relates to almost any aspect of pregnancy, we believe, but for sure preterm labor with just this one essential fatty acid, it has a huge effect.

Then you look at the incidence of preterm labor in the United States and what preterm labor does to the offspring and the cost of health care for that fetus, now infant, who was preterm delivered, and these become very large numbers. This is the other aspect of impacting disease: reducing stress on young families by simple interventions that we believe will have a huge effect on the health of the family and of the community and of the health care dollar.

IMCJ: It is one of those junction points where a clinician or practitioner has got a terrific opportunity to affect health significantly.

Michael: It is interesting, isn’t it, that all of us can impact health through a functional approach to health and disease. Through the perspective that we have chatted about today, it is clear to all of us that we have to query everyone about their earliest life. So no matter what the condition or what the age we wonder how early did their imbalance begin. So, for example, somebody comes in with hypertension and unknown risk of heart disease—no matter what the age— they look at us funny when we ask, “Do you have any knowledge of your birth history or what happened when your mom was pregnant with you?” There frequently is silence, followed by the quizzical “Huh? What are you talking about?” We then explain that we know the prenatal environment and nutritional status affecting the small or large birthweight babies can influence the number of nephrons in your kidney. And the person who was small or large at birth is going to react differently to medical or nutritional interventions for hypertension.¹² So this history of birthweight and maternal intrauterine environmental history is important not only for the individual but also potentially for their children and grandchildren to better understand the basis of their health conditions.

These are the opportunities to teach and help our clients understand that there is a reason they may not respond to therapies including medications, supplements, and food in the predicted way. What was set into motion a long time ago, very early in life, may still have an influence. This is empowering information. It is really the empowerment to change the knowledge base, so people can make informed choices that affect their condition and their health. That’s what we are all about.