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This week, we received a well thought out letter from Lisa, a visitor who really needed some answers about Pregnancy and Low Carbing. Because it's an issue we are asked about often and because so many women cannot locate any definite answers anywhere, we asked Lisa if we could share her questions and our answers with all of you in the hope that we can be of help to someone else wondering the same things... Dear Lora- I have a concern that I can't seem to find an answer for anywhere. I am 20 weeks pregnant with my fourth child in six years. Although I am thrilled to be carrying our fourth child, I am increasingly concerned at my quickly expanding waistline. I have gained a significant amount of weight (60 lbs) with all of my pregnancies but I clearly cannot do that this time or I will end up weighing well over 200 pounds when I am done. After the birth of my second child I was teaching seven aerobics classes a week and following a low fat diet and was discouraged because I could not break out of a size ten, two sizes away from my pre-pregnancy size. While at a local restaurant I got to talking with this nurse who recommended the Atkins Diet. I bought the book and in three weeks I went from a size ten to a size six. I don't think I had ever looked or felt better, even before I had children. Shortly after getting back down to my pre-pregnancy size I found that I was pregnant with our third child and let low-carbing go. I gained about 70 pound with our third and then only lost about 35 of it after I gave birth to her. Mostly because I was no longer exercising and my eating was terrible. I ate whatever I had time for, whether it was leftover box macaroni and cheese or a candy bar from the store. I think I began using sugar and carbohydrates as a sort of self medication. I started this pregnancy thirty pounds heavier than any of the others. I have spoken to my midwife about my concerns and she has told me to just concentrate on fruits, vegetables, and protein and rid myself of all white flour and white sugar to limit weight gain. Well I have done this and only gained eight pounds so far I am dangerously close to the 200 pound mark. Further more, every time I eat rice cakes, or any form of complex carbohydrates, I feel sick, tired, and weak. I really want to go back to low-carbing now, but everything I have found about carbs and pregnancy says that pregnancy is not the time to diet. And while I agree that I need to take in adequate calories during the day, I think that restricting my carbs will help me to feel better. The fact is I am about 50 pounds overweight, so I just don't need to gain any weight during this pregnancy. I think the pregnancy books are simply giving a "safe answer" that society and the medical community feels is in line with the current food pyramid. My concern is the effect being in ketosis will have on the baby. I was wondering if you have heard anything about the effects that ketosis could have on the baby. I am not seeking medical advice from you, I will definitely discuss it further with my midwife, it just seems that there is no information out there about continuing the low-carb lifestyle during pregnancy. Any info you have not his subject would be greatly appreciated. Sincerely, Lisa

Dear Lisa — Thank you for your thoughtful letter and for sharing some of your history and thoughts about where to go from here. The questions about Low Carb and Pregnancy are actually quite regular ones. It's common for people to say they were unable to find an answer about "the safety of low carbing while pregnant" online or anywhere else. My opinion about the lack of such answers is probably a pretty simple one. No one wants to advise anyone to follow a specific path when there's no finite research study, or generally accepted rule to save them from liability if they are perceived as giving medical advice. Therefore, I will start my answer, as I have to, by saying that these are simply my opinions, and what I would do were it me, and do not purport to offer advice or counseling of a medical nature. It's my belief that no one — pregnant or not — needs a diet filled with refined flours (or things made with them including standard commercial pastas) or refined sugars. Nor do they need hydrogenated oils (trans fats.) Those are just a given. But to keep your weight in line and still feel comfortable about the issue of ketosis, I would do the following: Stay low(er) carb in all your menu choices taking care to get enough carbs just to keep you out of ketosis — for most people about 65 to 75 carbs a day are guaranteed to stay out of ketosis but also avoid weight gain (and often still lose just a little at a slow safe rate.) Once you've had the baby, you can feel free to lower carbs, get into ketosis, and lose additional weight. (If you plan to nurse, you might consider waiting on returning to a ketogenic diet until nursing stops.) However, where those 65-75 carbs come from is really important during pregnancy. You could get that result by eating all fat and protein most of the day and then just splurge on a milkshake or pastry containing 70 grams of sugar, but that would be stupid and dangerous. So use your common sense and try and follow these guidelines: Eat numerous times throughout the day and spread your carbohydrate grams out pretty evenly through those small meals. Wherever possible, make your carbs come 60% from vegetables (and don't count potatoes or rice among them!); 15% from low sugar fruits (berries, melons, peaches, plums, etc.); and 25% from WHOLE grains - oat, buckwheat, rye, and some wheat. While pregnant, I'd avoid the low carb "specialty" products that contain polyols (sugar alcohols) such as maltitol, sorbitol, lactitol, mannitol, etc. Include salmon or other fish (salmon's best, though) several times a month in your diet. If you like salmon, have it once a week. Including flaxseed is also a great idea. You want to get those healthy Omega-3 fatty acids! NOTE: Don't over-do fish (salmon, tuna, mackerel, etc.) Note that we said several times a month, not several times a week. The healthful benefits of fish and fish oils must be weighed against the worry of possible mercury hazards in such fish, and the risk of damage to the fetus because of it. Mercury is a metal believed harmful to the growing brains of fetuses and young children. Typically, the largest fish contain the most mercury. Paradoxically, fish also contains fats very important for fetal brain development... And don't assume this means switching to fresh fish, rather than canned, is safer. In fact, women could absorb far more mercury if they also eat freshwater fish that friends or family catch in local lakes or rivers. Some state waters are heavily polluted with mercury, and the FDA doesn't regulate recreationally caught fish. Most experts agree that the safest course is to eat fish a few times per month for the health benefits, but not more than once a week when pregnant to avoid mercury contamination. Keep up an adequate intake of water each day... I know, when you're pregnant you already feel you have to pee every five seconds, so you'll be tempted to skip the extra fluid, but don't. It's ever so important. Make nuts — especially almonds — a regular snack. They're high in satiety value, filled with vitamins and minerals, and also high in Omega-3's. Take your supplements. Always take calcium along WITH magnesium so it can be properly absorbed. Take a multivitamin without iron. Take Acetyl L-Carnitine. Take CoEnzyme Q-10 (about 100 mg daily.) OR whatever is recommended to you by your doctor. Stay active. Maintain whatever exercise regime you and your doctor are comfortable with, but staying active keeps your metabolic rate steady and prevents after-pregnancy weight gain. Wherever possible, get the refined sugars and starches out of the house. Ditto for trans fats like margarine and shortening. Stay prepared. Keep acceptable and healthy foods as discussed above on-hand, so when hunger strikes and time is short, you won't be tempted to grab something convenient, but destructive. I find that keeping things pre-made in the fridge like sliced roast beef, sliced cheeses, tuna, chicken, or egg salads, or other protein snacks is a lifesaver. I hope these suggestions help, and they are precisely the plan I'd do if I were pregnant, and what I'd recommend to a friend or relative. Best of luck and Have a Happy Healthy Baby!!

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