“Nutrition in Twin Pregnancies: Simple, yet Critical” – with Dr. Barbara Luke

Dr. Fox: Welcome to today’s episode of “Healthful Woman,” a podcast designed to explore topics in women’s health at all stages of life. I’m your host, Dr. Nathan Fox, an OB-GYN and maternal-fetal medicine specialist practicing in New York City. At “Healthful Woman,” I speak with leaders in the field to help you learn more about women’s health, pregnancy, and wellness. All right, Dr. Barbara Luke, thank you so much for coming on the podcast. It is great to talk to you. How’s life?
Barbara: Life’s good.
Dr. Fox: So, you’re in the great state of Michigan, enjoying the cold weather.
Barbara: Yep, we have snow on the ground. It’s 22 degrees. Yeah, long winters in Michigan.
Dr. Fox: Beautiful. People are gonna think we’re recording in August and there’s snow on the ground. No, it is December, so, there’s expected to be snow in Michigan. For some of our listeners, they will already know who you are by reputation. Others will not. But I will state that you are like the person when it comes to nutrition and twins. You’re an author of a book on when you’re expecting twins, and there’s a ton of stuff on nutrition there. You are an MPH, you’re a reproductive epidemiologist, you’re a nurse, you’re a doctor of science, you’re a nutritionist, and you are all over twin nutrition. So, I’m so happy to have you here. Welcome.
Barbara: For me, prenatal nutrition is the most preventive medicine you could possibly do. I mean, so many women, when they get pregnant, it’s sort of clean slate, “What can I do to have the healthiest diet, the healthiest pregnancy?” And nutrition is the one factor that’s completely under there.
Dr. Fox: And it’s low-cost. It’s like everyone thinks it’s fancy. And, honestly, you know, just nutrition, particularly with twins, it is such an important aspect of it. And I think that it’s…you know, we’re always looking for the next new thing and this is always been there and it is really important, I agree. I want you to give our listeners a sense just who you are, like, where you came from originally, and how you got to hear…this could be a very long tale but just hit the highlights just so we can, sort of, understand your arc to where you are now.
Barbara: My undergraduate degree is in nursing. My father would only let me go to college if I studied nursing, which my mother was a nurse. And I started in…I went to Columbia University. So, graduated, went into the Visiting Nurse Service, which is one of the oldest in the country, and did public health nursing in the South Bronx, Lower East Side, and took care of things that never got better, people at the end of their lives, diabetic problems, wounds that never healed.
And I got very discouraged, as a young person, starting in medicine, and decided to either do something more positive, more preventive, or get out of medicine completely. I was brought up in a home of arts, so that was my other calling, and I do that really for my own pleasure. But I decided to go back and get a master’s in foods and nutrition. And I’m a native New Yorker. I went to NYU and became a registered dietitian. And I approached the people at Columbia Presbyterian to start a prenatal nutrition program. And they were very receptive, I started back in 1974.
Dr. Fox: Why prenatal?
Barbara: Part of my master’s degree, I had done a project on prenatal nutrition. And to me, it’s the most positive and preventive medicine you could possibly do, building healthy babies.
Dr. Fox: And, in 1974, this is basically predating most of ultrasound, this is predating most of genetic testing, this is really just at the time where you’re lucky if your doctor told you not to smoke.
Barbara: I started a WIP [SP] program, which is now the SNAP program, I wrote a grant and we got a program for Columbia Presbyterian. It’s still operating today 50 years later. So, when I started my program, actually I’ve flooded with patients. The residents and attendings loved that there was someone who would talk to patients about nutrition.
Nice thing about pregnancy is it starts, it ends, and there’s things you can measure. So, weight gain, someone’s diet, we would do blood glucose at 28 weeks. A lot of things we could measure. And what I started to notice is that women pregnant with twins, there were no guidelines. And there were some women who did very well with twins, others who did terribly.
So, when I went back to literature, there was lots of hand-wringing, isn’t it a [inaudible 00:05:01]? Twins are small, born premature. And I thought, “No, they’re not all small. What is associated with nice big twins?” And I did pilot studies and, eventually, went on and got my doctorate in perinatal epidemiology, reproductive epidemiology, at Hopkins, and looked at a decade of twin births in Baltimore.
Now, Baltimore is an interesting city in that people tend to stay there. You open someone’s medical record, there’s their birth certificate, their whole childhood, and then each of their pregnancies. So, when I was looking at women having twins, I actually knew a lot about their childhood before they even got pregnant. But 10 years’ worth of twins was enough for a dissertation, not enough really for research.
So, I formed a consortium around the country of people interested in multiple births. Basically, we had four universities, continued with Hopkins, Medical University of South Carolina with Roger Newman. He has the longest running twin program in the country, started in 1987. The University of Michigan, Tim Johnson was chosen to be the chair of OB-GYN, and he was at Hopkins when I was there. And he recruited me to start the twin program at University of Michigan. And the other was Mary Jo O’Sullivan who was a maternal-fetal medicine physician at University of Miami, at Jackson Memorial.
So, these were four very different locations. And we pooled our data, we pooled every aspect of multiple pregnancy. Eventually, ultrasound cost, length of stay, and, of course, weight gain, placental pathology, all the labs. So, what started as just a couple of hundred twin births ended up being 3,600 with comprehensive data on all different aspects. And we published a great deal of research.
And the research I’m most proud of is we looked at pregnancies that ended with nice big, healthy children, about 6.5 to 7 pounds each for the twins born at 37 to 39 weeks without complications. And we looked backwards at what these women weighed before they were pregnant. So, underweight, normal weight, overweight, and obese.
And we modeled the data to see how much they gained by each trimester. And to take it further, it actually ended up being the first half of pregnancy, by 20 weeks, by 28 weeks, and then by term, 38 weeks. That particular piece of research, the National Academy of Sciences, the Institute of Medicine took as the first national recommendations for weight gain in twin pregnancies.
Dr. Fox: Yeah. I wanted to ask you this for a moment because, you know, you’re talking about this massive consortium of twins, you’re talking about tons of publications from you guys. And these are the ones that any of us who are interested in twins, and read about twins, and do research about twins, and publish about twins, you know, we see these articles, we quote these articles, we read these articles. You know, we’re all over them.
One of the unique things about it, other than the fact that this was such a comprehensive program running for so long, is the person, sort of, overseeing all of it, you, your primary degree was in nursing. People, sort of, always expect, when they run into Dr. Barbara Luke who ran the whole twin program, that you’re an MFM, you’re an OB-GYN, or whatever. And your original degree is in nursing.
And I’m curious, when this was happening, did you have any trouble, sort of, getting off the ground or getting people to buy in because of that? You know, I’m not saying it’s a reality that it should be a problem, but I’m curious, did you have that? Was there like a stigma because you weren’t “the doctor” initially?
Barbara: Well, I’ll tell you, I don’t dye my hair anymore. I’ve got lots of white hair. Being a woman in medicine, being a nurse in medicine, when I became a professor, that changed the rules a bit. You have to be twice as good as a physician, you have to know what they know and more. Most physicians don’t know much about nutrition. There’s a lot of other things they need to learn.
So, my master’s is in food and nutrition. And, actually, the book I wrote for parents, there’s a big section on recipes, all of which I invented. But I learned how to write recipes. I had cooking labs. I have skills that the physicians don’t have. Plus, I had a number of good mentors and advocates all along the way, physicians who realized this was a powerful tool. They would much rather deliver 7-pound twins than 3-pound twins. It was much more gratifying.
Dr. Fox: I think it is a testament also not just to you and your, you know, abilities and your fortitude, but also to the doctors that you teamed up with, for their ability to, sort of, see beyond all these things and realize, “This is good for research, this is good for the patients,” it’s good for them. Yeah. They probably didn’t know much about nutrition.
They’re like, you know, “Here’s this professor who knows so much about this, and can really, A, help our patients and, B, help us learn more about it.” And I think that it’s great. I mean, you’re still working with all them. I mean, this is who you write the book with, you know. And, so it’s pretty cool that you’ve had such a long relationship with them. And I think it’s a fantastic example of collaboration that we don’t always see out there.
Barbara: But it takes an effort. You know, whenever you work with other disciplines, you need to learn about them, they need to learn about you. It’s easy to work within your own little world. It takes much more effort to span disciplines. And I am a member of the American College of OB-GYN, I’m a member of the Society for Maternal-Fetal Medicine. I present at these meetings and I get challenged. I get challenged from the audience. But the science is really solid. I’d say you have to be extra careful when you are really outside your main field.
Sample size is always important. To me, that’s the single biggest flaw in a lot of medical research, is inadequate sample size. People make sweeping conclusions on small sample sizes, and it may not be accurate. I mean, I could’ve just stuck with the few hundred twin pregnancies that was the basis of my dissertation, but, to me, it wasn’t enough. We needed more racial diversity. We needed larger numbers. With twins, you’ve got monozygotic, dizygotic, you’ve got, you know, chorionicity, you’ve got placental issues. So, more numbers are always better in nearly every area of research.
Dr. Fox: And it’s also nice because, when you have a large sample, like you did, and you do, and you publish on, when others, you know, look at their own data, we can see how it’s similar and how it’s different. I know, when we looked at our own data and published it, we had the same findings as you. Like what you described before about, you know, the people who had full-term, big babies that were healthy and went back, we saw the same thing, very, very early weight gain was directly correlated to how far pregnant they got and how big the babies were. Sort of, both.
Barbara: Exactly.
Dr. Fox: And how big the babies were wasn’t as surprising to people, I think. I think there’s some logic, you know, to that, all right, you eat more, you take more calories, you get more healthy food, the babies will grow better, but that you would stay pregnant longer, that you guys saw and that we saw, I think, was surprising to a lot of people. Was that surprising to you when you first saw it?
Barbara: Well, when we really thought about it, the early weight gain makes a good placenta, and expands the blood volume. So it’s like a garden. You know, if you’re really getting everything ready, growth is gonna take off. And that’s what we saw. When all the components were good, when everything was in place, growth just continued, continued like singletons, which, if you think of it, every child has the potential to grow like a singleton.
And that really was our goal, because once growth starts to fall off that curve, it doesn’t recover. So, if you can keep them growing well, as long as possible, you’re going to have nice-sized mature babies at birth. It’s all those ingredients. If the placenta is good, if the mother is healthy and she’s got a good blood volume, lots of iron on board, good calcium, a good diet, growth just continues.
It’s amazing how many pregnancies, delivery had to be induced because the woman was so uncomfortable, the children were so big, and she’d gone past 39 or 40 weeks with twins. You know, the children start to lose weight after a while. But, yes, it was surprising, but it was gratifying. It’s like, “Yes. This is the recipe for a healthy pregnancy.”
Dr. Fox: How do you feel about this idea? There’s a lot of debate, like, in the ultrasound world, in the MFM world, about, since twins are so commonly smaller than singletons, whether we should be saying that’s “normal?” Like the new normal. Or it’s so common that they have that abnormality that they’re not growing. Meaning, since, like, the average birth weight of twins in each week of pregnancy is gonna be lower than a singleton, a lot of people say, “Oh, that’s adaptive. That’s the twins, like, intentionally taking less calories to save themselves.” I’m not a big fan of that, either.
I tell people, just because something happens commonly doesn’t mean it’s normal. I mean, twins commonly deliver prematurely. That’s not good for them. It’s not good to be born in 35 weeks necessarily, even though that’s common. And so, if the babies are small, just because it’s common, I don’t think that that’s necessarily normal.
So, I’m pretty sure I knew how you were gonna answer that question, but I want you to talk about it for a little bit, because people do hear that, and there’s a lot of debate about what to do. You know, if you see a twin who’s, you know, measuring in the 10th percentile for a singleton. [Inaudible 00:15:59] oh, for a twin, that’s the 50th percentile. And a lot of people say you should do that.
Barbara: No. I mean, like I said earlier, every child has the potential to be nice and big. And if the mother is tall, particularly it’s a larger uterus, there’s more room to grow. There is that potential to be 7, 8 pounds. Now, there may be factors in the placenta, there may be factors in the mother’s health, but to set that standard lower is to buy into growth restriction.
Dr. Fox: It’s like when they changed the norms on the SAT. Everyone started doing better. “Hey, I got a better score.”
Barbara: Yeah. I don’t buy it. This has been a debate in the twin societies for a long time, and I don’t agree with separate standards.
Dr. Fox: Yeah. We also rarely have twins go past 38 weeks anymore because, like you said, there’s diminishing returns and risk of stillbirth. So, we don’t get a lot of 9-pound twins because they just aren’t pregnant long enough to get to that point. Occasionally, but that’s another factor, obviously. And, was there anything else about your research, or your findings in your research that was surprising to you?
Barbara: Body image is an issue, and getting women to gain weight after so many years of trying not to gain weight. And this is really, the weight-gain recommendations that we’ve shown, this early weight gain and less weight gain in the third trimester is opposite of what the Institute of Medicine suggests for singletons. I think their recommendations are wrong. The babies are growing fastest in the third trimester, second and third, and really using what is basically put on board for the mom.
So, we actually see arm circumference come down a little bit. Those fat stores are mobilized. So this rapid mobilization of weight. There’s fat that’s put on in the woman’s legs, her arms. We know that. But it’s there not only for pregnancy, but also for lactation. And there have been studies done that have shown that to get your metabolism back on track, you need to breastfeed. And if you don’t breastfeed, your metabolism will not recover as quickly after delivery. So, although it’s a challenge with twins, I would recommend it. I mean, there’s so many reasons to breastfeed. But one is a selfish reason, to get your body back into shape.
Dr. Fox: Yeah. I mean, because when I talk to women with twins about nutrition, you know, sort of, start the conversation…you know, like you said, I’m not a nutritionist. I don’t have, you know, advanced understanding of all of the, you know, micronutrients and, you know, all the tricks of the trade, and whatnot. But, you know, I have a working knowledge of it, and I generally just start with, you know, weight gain just so their expectations are set.
And when I tell women, sort of, the recommended weight gain based on, you know, their starting, you know, body-mass index and their weight, they’re like, “What?” You know, because it’s…and for, you know, sort of, an average-weight woman, you’re talking a pound a week, give or take, over the course of her pregnancy.
And, you know, that comes to, ballpark, you know, 30 to 40 pounds. And for someone of a normal weight, that’s, well, scary to them. Number one, like, they don’t wanna do that. Number two, how are they gonna necessarily achieve that? It’s not as easy as you would think. For some people it is, and others, it’s not because, you know, as you get more pregnant, your stomach gets more full and it’s harder to take in some of these meals. And that’s where a lot of…you know, a good nutritionist can help you with high-calorie, and high-protein, and high-vitamin foods, and how to do that.
Did you find, in your multiples clinic, that the women who achieved the weight gain, sort of, in a healthy way, you know, with your direction and, you know, postpartum, saw you, and followed with you, and, hopefully, were nursing as well, that they were able to take off the weight? Meaning, were you able to be encouraging with them that, “Hey, listen, it’s a lot of weight to gain, but it’s gonna come off?”
Barbara: Yes. Absolutely. Actually, women who had the hardest time with gaining weight were overweight women, because they’ve struggled with their weight for so long. So, when I would tell them to drink milk, whole milk at lunch, it’s like, “What?”
Dr. Fox: It’s poison.
Barbara: “I’m used to diet soda.” You know, “Have ham and cheese, you know, omelet for breakfast. And put cheese on your toasts,” adding the calories. But, suddenly, they felt so much better. They weren’t ravenously hungry by the end of the day, which is how many overweight women, they start every day as a diet, sort of, punishing themselves, “You’re not allowed to have calories.” But, by the end of the day, splurging.
Dr. Fox: Yeah. I mean, the weight gain is a little bit less if you started overweight or higher, you know, but it is more than they were expecting, and more than in a singleton pregnancy. If you’re carrying one baby, we’re pretty…I wanna say, I guess, lenient with not gaining weight frequently with one baby. But with twins it’s not the same, because they still need the calories. And it’s not all gonna come from maternal fat stores. It has to come from what you’re eating. It’s an important part.
And so, you know, all of our women with twins are seeing a nutritionist, and following. And, like I said, some find it easier, some find it harder, but it is work. It tends to be…and like you said, it’s really the one thing that’s under someone’s control.
You know, we know that, like, better rest is not that helpful, and most of the medications we have for these things are not so helpful. And ultrasounds have their role for certain things, but they’re not gonna make the babies grow better, that’s for sure. And this is like the simplest, in terms of technology, way to do it. I don’t want to say “it’s simple” to minimize. It is work to do this, but it is pretty low-tech, fortunately.
Barbara: You know, you mentioned ultrasound. We use that as a goal every month, the estimated weight. And we also use femur length, head circumference, the individual measures to watch how the children are growing. That is incredibly useful. Don’t wait for birth weight. Look at how they’re growing every single month as a goal. Let’s keep them growing at a good rate rather than waiting for the surprise, you know, at the end.
Dr. Fox: I wanted to give you an opportunity to talk about your research. Specifically because…I’m gonna ask you about, you know, recommendations that you would make, so, you know, women listening who are carrying twins and wanna say, “Hey, specifically, like, what does Dr. Luke think I should do?” And all this. But just so people understand the reason these recommendations are there.
I mean, you published an amazing study. I know that you know the study. I quote it all the time, where you looked at the women who were enrolled in this intensive twin program that included, you know, frequent visits, and nutritional counseling, and, you know, dietary help, and everything you’re talking about. And, essentially, you published this…and we’re talking, it’s almost 20 years now. You published in 2003 I think, right?
Barbara: Mm-hmm.
Dr. Fox: And, you know, you’re talking about twice-monthly visits with dietary education, they were getting 3,000 to 4,000 kilocalories a day, with supplements, and you had your weight gain goals, and you compared those twins to the ones who didn’t. Now, it wasn’t what we call “randomized,” where you, sort of, randomly choose people into the program or not, which would be perfect, but instead they were self-selected. Okay, there’s some downside to that, but the differences between those groups were so impressive.
I mean, you’re talking about the likelihood of delivering under 32 weeks. It’s 2-months premature in your cohort of 7% versus 21%. The chance of preeclampsia. Why would this affect preeclampsia? Well, healthy pregnancy is a good way to prevent preeclampsia, 8% versus 17%. And you also had improved neonatal outcomes, birth weight, NICU admission, morbidity. I want you to talk about that. When you did that study, what kind of an impact did it have, sort of, in practice around, you know, 2003?
Barbara: Well, we actually even got a grant from the Gerber Foundation, which is based here in Michigan, to follow those children, and the controls for 3 years. And the chances of better development, neurologic development, growth, being readmitted was much less likely. If you’re born healthy, chances are you’re gonna stay healthy.
We tried to do this as a randomized trial. And we approached…we wrote NIH grants. We got up to $21-million NIH grants’ sites around the country, and we were turned down. And at that point, I was so fed up. I said, “Let me just take this to the streets. Let me take it to the people. If NIH is not gonna fund a randomized trial with this kind of evidence, then let me just take it to the families that this affects the most, and explain to them what this entails and how they can do it.”
Dr. Fox: Why do you think they didn’t approve?
Barbara: Who knows? Who knows? A lot of medicine is pharmaceutically-oriented.
Dr. Fox: Fair. Okay.
Barbara: Anyone who eats breakfast is a nutrition expert.
Dr. Fox: Does iced coffee count?
Barbara: Yeah. Who knows? So that’s when we decided to write a book. And I partnered with a professional writer who herself had twins. She’d actually interviewed me a number of times, Tamara Eberlein. And our first little book was not very long. We just hit 1,000 reviews on Amazon. And we’re gonna write a fifth edition. So it’s been in print for a long time. The first book was under 200 pages. It’s now 650. So, yeah, it’s done extremely well.
And, basically, it’s a common-sense recipe. I picked best evidence, all the components are basically best evidence, what works. We know the most about a diabetic diet. That’s the oldest diet, the most studied diet ever. And it’s a very balanced diet, the idea that your blood sugar should be stable. If your blood sugar goes too high, goes too low, bad things happen. And particularly fetal growth, we want growth to be as normal as possible. Like I said before, once growth starts to fall, it doesn’t recover. So you only have this one chance. And diet is the biggest influence over your blood-sugar level.
Protein, the only thing that builds tissue is protein. And certainly my vegetarian patients did not do as well as those who grew up on farms, and drank milk, and ate eggs, and meat, and chicken. Makes a huge difference. Iron is a limiting factor for growth. Vitamin D is extremely important. We recommend every woman gets her vitamin D level checked. There’s certain supplements that a woman should take. Folic acid is one of them. Folic acid is not stable in food, so it’s better to take it as a supplement.
The other is omega-3s. Very few women eat a lot of fish. And the fish we get, we’re not sure about pollutants. So pharmaceutical-grade omega-3s are very important for brain growth, for neurologic development. So, even if the twins are born prematurely, they’re less likely to have neurological sequelae.
Dr. Fox: Let’s start with that. So, someone comes to you, they’re newly pregnant with twins. And everything’s going okay from the pregnancy side, and, you know, she has no medical issues, and she’s starting with, let’s say, a normal body weight. So, you know, we’ll start from there. And she says, “Okay, what do I need to do in terms of, let’s say, calories, and then in terms of, let’s say, supplements, and then in terms of weight gain?” How would you, sort of…if you had to list it for them as a summary?
Barbara: So, weight-gain goals are actually not by trimester. As I said earlier, when we did our paper that the National Academy of Sciences took as recommendations, we actually found that it was this long runway, was the goal by the first half of pregnancy, and then by 28 weeks, and then 38 weeks. So, depending on what her pregravid weight was, underweight, normal weight, overweight, obese, we talk about, what is the weight gain goal by 20 weeks?
From conception to 20, and 20 to 28 are the most critical periods for fetal growth. After 28 weeks, it really doesn’t make much difference what a woman gains. And actually, she can really…you’re big by that point. It’s hard to eat much at any point after 28 weeks. And that’s when the fat stores get mobilized.
The other is calories don’t really mean much to the average person. It’s really, what do you eat, and how much? That’s what we would go over. When patients would see me every week or every other week, I would ask them, “What did you have for breakfast? What did you have for lunch? What did you have in between meals?” So frequent meals, and always protein and carbohydrate together.
And the reason for that is that if you just eat carbohydrates, just eat fruit, just eat cookies, just eat bread, your blood sugar goes up and then it drops. And that’s not what you want when you’re pregnant. You want a stable blood sugar level. So protein and fat will help keep your blood sugar at a nice steady rate. Dairy before bed. Ice cream is therapeutic because it’s…I love my job. It’s broken down slowly and gets you through the night.
Dr. Fox: The benefits of a milkshake, it’s really whole-milk milkshake.
Barbara: Well, or ice cream, you know, just before you go to bed. Doesn’t have to be a lot. I don’t have stock in Ben & Jerry’s.
Dr. Fox: Ben & Jerry & Barbara’s.
Barbara: Right. It’s just the idea that, you know, you can’t go to bed on an empty stomach. And you want to sleep. You want these kids to grow all night long, and you need your sleep. So Barbara tells you to eat ice cream before you go to bed.
Dr. Fox: Do you notice that in, at least American women’s diets, one of those is lacking the most? Would you say it’s protein, or would you say it’s eating protein and carbs together? Or would you say people are so worried about eating fat that they won’t have, you know, higher fat foods in pregnancy? Like, what tends to be people’s, you know, difficulty or sticking point with this kind of diet?
Barbara: Well, protein, men need much more protein than women. And I had a number of vegetarians who, you know, I convinced them, “Unless it was for religious reasons, please, just you and your husband get off the vegetarian diet while you’re pregnant. Go back after you deliver” But this is the easiest, quickest way to build children. It takes protein to build protein. You want nice-sized children. You know, it’s the best gift you could ever give your child, to be well-grown at birth.
Dr. Fox: It’s not an iPad? Are you sure? I thought an iPad at age 5. Okay. What’s your view on plant-based protein? Because that’s a big thing nowadays, you know, vegan diets, plant-based protein, it’s gonna save the world, and cure cancer, and solve the crisis in the Middle East and everything. What do you think about that?
Barbara: There’s two kinds of iron. There’s heme iron and non-heme iron. Heme iron is much more readily absorbed. Non-heme iron is like the iron in plant protein. Is affected by fiber, it’s affected by everything else in the diet, calcium…is, you know, very, very poorly absorbed. And iron is a limiting factor for growth. Here we get back to square one again. Growth is the most important factor. You want these children growing well.
And there’s other tissue you’re building. You’re building the placenta. You’re building your blood supply. You’re expanding that blood supply. So iron is critical not just for the children, but for the pregnancy. So plant protein, you would have to eat a lot of it, and you’re still not going to get the nutrients you really need. So, you know, you have one chance to build these children. A lot of these dietary decisions are social, and that’s fine, but as an adult, you’re fully made. You’re fully formed. It is not as critical as when you are pregnant.
Dr. Fox: Got it. So plant-based protein diets and twins, Barbara Luke, not a fan. All right.
Barbara: Not a fan.
Dr. Fox: Not a fan. And then, in terms of other, let’s say, supplements, you mentioned iron that pretty much everyone’s gonna need to be on some form of iron, unless they eat a tremendous amount of meat. Is that correct?
Barbara: Well, I actually don’t like iron supplements. They’re non-heme iron.
Dr. Fox: They’re unpleasant.
Barbara: Right. And they’re hard to take. They’re hard in your stomach. So I don’t use irons. I don’t recommend iron supplements. I said folic acid, I recommend. Calcium, magnesium, and zinc as a supplement, unless you are a big dairy fan. Most women are not. Calcium, magnesium, and zinc are the nutrients the World Health Organization has found to be most lacking in women’s diets.
And calcium, magnesium, and zinc are critical for fetal development. I mean, zinc has to do with…actually breaks the cell walls in viruses and bacteria. So it has an antibacterial effect. Magnesium is protective of the developing nervous system. Calcium has been shown to reduce preeclampsia. So there are three nutrients that are powerhouses for complications in pregnancy.
Like I said, omega-3s, most women don’t get enough. They’re essential fatty acids. You know, unless you’re eating a lot of fish, which most women don’t do, better to get them as supplements. And vitamin D, you should have your vitamin D level checked. Depending on where you live, you may have low levels. That’s related to infection and prematurity. So you may need to take vitamin D in proportion to how deficient you are. So that’s one test that your doctor should run.
Dr. Fox: Yeah. And then, in our practice, we recommend that all women with twins see a nutritionist formally. And I’m sure you’re gonna be in favor of that, so I don’t have to ask you. But just so our listeners understand, what is it that a nutritionist, a dietitian is going to be able to do with someone who’s pregnant? And in what way will they help that their doctor may not be able to, or they may not be able to get on the Google, for example?
Barbara: Well, plan a diet within what foods they like and don’t like within their means. Not everyone can afford organic food in farmers markets. Some people have very hectic lives. You know, how to plan meals so that you don’t have to cook every day. How to plan a balance. You know, asking for calories, calories don’t mean much. They’re numbers.
In a practical way, you know, what a nutritionist can do is make recommendations for what you should eat, plan your meals, help you with grocery lists. You know, “How can I map out, sort of, the best food course for this pregnancy? You know, I don’t like milk, or I’m allergic to eggs. Can you help me figure out where I can get my protein, or my calcium? What’s a good lunch that I can take to work?” I mean, you know, people are taking lunches to work.
Dr. Fox: “What’s a good lunch that I can order on Uber Eats at work?”
Barbara: Right. You know, “I want to go out to eat. I want to have Chinese tonight. What should I order? Can I have pizza? And what should I put on it?” “Of course, you can have pizza.” “What’s a good breakfast?” You know, it’s sort of the practical side of it, but with the science behind it.
Dr. Fox: You’ve been doing this a long time. You’ve thought about this a long time. You’ve been helping people for a long time. I’m just curious, sort of, from an overall perspective, both looking back, but also looking ahead, what do you see is maybe the biggest challenge we face ahead, or something that we’re really gonna need to continue to work on moving forward, either for yourself or if you pass that baton to somebody else?
Barbara: Boy, that’s a big-picture question.
Dr. Fox: Yeah. We’re big. This is not a fluff podcast. We get right in there, you know. We’re doing this.
Barbara: Well, to me, nutrition is critical. There was a paper I read when I was finishing my master’s back in 1974. And it was done by a pathologist at Columbia Presbyterian. And it was unusual and it stuck with me my entire career. He was a pathologist. So he looked at these children who died during labor. They died of cord problems, which does not happen today, has not happened for 20 years because of monitoring during labor. But back then, this happened.
Like you say, it’s before ultrasound, before a lot of things. What he found is that children born small for gestational age, there was brain-sparing. The brain was a good size, but other organs were a third or a half the size, had fewer cells, the kidneys, the liver, the pancreas. And if those children had lived, this would have translated into chronic disease. So children born small for gestational age have this deficit right in the beginning.
There’s a reason children should be born nice, and big, and healthy. They start their life with the complement of healthy organs to begin a healthy life, and that nutrition is really at the heart of all of that. Where are we going to get the iron? Where are we going to get the protein? Where is it going to come from? It’s not from food. It doesn’t come from the mother. She pays the price that even that is not a perfect match. The mother will survive if the baby is not doing well. So, to keep a healthy mother and healthy babies, nutrition is really at the heart of good prenatal care.
Dr. Fox: Barbara, thank you so much for agreeing to come on the podcast. I loved you before I knew you. And then once I knew you, I loved you more. And you have this book. It’s called “When You’re Expecting Twins, Triplets, or Quads: Proven Guidelines for a Healthy Multiple Pregnancy.” You’re the first author. It’s a great book. It’s such a great book that I know that there’s some idiots who’s quoted on the front cover of your book saying, “This book is both thorough and practical, and offers expert insights and evidence-based information on how to optimize outcomes for multiple pregnancies. It is essential reading for women expecting multiples.”
And that idiot’s name is Nathan Fox, MD. Maternal-Fetal Medicine Associates in New York, and father of twins. I think I would have said something snappier now. I would have said something like, “This book is better than cats,” or something, which probably would have sold you more copies. But I had to sound like a doctor on the quote. But, no. It’s…yeah.
Barbara: It’s a wonderful quote.
Dr. Fox: Listen, I’m honored that you asked me to put something on the cover. But, listen, it’s the book I recommend to, you know, the women I see who are expecting twins. And I say, “Listen, just read this. Read the nutrition chapters. Read nothing else. Read that.” And it’s mind-blowing for people. It’s not what they would have expected, but it’s good stuff.
And I not only appreciate you coming on the podcast, but obviously all these years of the research you’ve been doing and, you know, the education you’ve been providing not just to your own patients, but to all of us who take care of twins nationally, internationally. What we do is different because of the work you put into it. And it’s a big accomplishment.
Barbara: Thank you so much.
Dr. Fox: It is. It’s a big thing. Good stuff. Enjoy the freezing cold.
Barbara: Thank you for inviting me.
Dr. Fox: Thank you for listening to the “Healthful Woman” podcast. To learn more about our podcast, please visit our website at www.healthfulwoman.com. If you have any questions about this podcast, or any other topic you would like us to address, please feel free to email us at hw@healthfulwoman.com. Have a great day. The information discussed in “Healthful Woman” is intended for educational uses only. It does not replace medical care from your physician.
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