Alexandra Rothwell Kelly is a San Francisco based Registered Dietitian with a Masters in Public Health and over a decade of experience working in the nutrition field. She has developed wellness programming and performed clinical research in integrative medicine and health technology. Alexandra conducts individualized nutrition and lifestyle counseling with a “whole-food” approach and a focus on fertility, pre- and post-natal nutrition, digestion, inflammation, hormonal health, and optimizing energy levels and performance.
We sat down with Alex to discuss pregnancy, postpartum, and healthy eating.
1. Do you recommend eating plant-based while pregnant?
I recommend eating a “plant-heavy” diet during pregnancy but not entirely vegan, unless the woman is opposed to eating animal products for ethical or religious reasons. This can be a tricky topic to approach, as many of us believe so strongly in a particular way of eating, that diet can become somewhat of a religion. Note that I am not being judgmental of anyone’s food choices, merely trying to help people make informed decisions for their health.
A plant-heavy diet is recommended throughout life but is especially important during pregnancy, when a woman’s nutrient needs are elevated and her dietary choices impact the health of the tiny human she’s growing. Non-starchy vegetables (leafy greens, broccoli, peppers, etc.) should make up the bulk of meals, and should be included in a wide variety for optimal nutrient exposure. The common advice to eat a rainbow of vegetables is based in the idea that nutrients provide specific coloring to plants, and by eating several colors throughout the day, one will achieve the greatest nutritional diversity. Folate is a micronutrient of particular importance during pregnancy, as deficiency can cause defects to the baby’s brain and spinal cord. Leafy green vegetables and beans are some of the best sources of folate, which is reason enough to get plenty of these foods before and during the prenatal period.
Vegetables are also rich in fiber, which is especially helpful during pregnancy for a few reasons. First, expecting mothers experience higher than normal blood sugar levels, and fiber can help to regulate this by slowing down the rate at which the body processes carbohydrates. Vegetables are also a source of “prebiotic” fiber, which acts to feed the healthy bacteria in the intestines, which are associated with improved gastrointestinal health as well as several other health benefits. Lastly, constipation is a common complaint throughout pregnancy, and the fiber from vegetables can help to make bowel movements more frequent.
There are a few nutrients, which are either only available or much more bioavailable in animal products, which is why I recommend not eating entirely plant-based during pregnancy. Vegans or vegetarians may want to speak with a dietitian to ensure that they are supplementing appropriately during this important time.
2. What types of nutrients are essential to pregnant women?
To answer this question completely would necessitate writing a textbook, so I’ll focus on a few key nutrients and food groups.
Fats: Many women have a fear of eating fat, but the need for nutrients found in healthy fat sources increases during pregnancy. Olives, coconut, nuts, seeds, avocados, and well sourced animal fats are all excellent sources of nutrition. A type of omega 3 fat, called DHA is of particular importance to the baby for its role in brain and vision development. DHA is primarily found in animal products, such as fish, eggs, and grass fed-beef, so vegans and vegetarians should consider supplementing with an algae-based product. Choline is another fat-derived nutrient with a strong role in brain development that can be found in egg yolks and peanuts.
Fermented foods: Pregnancy is an ideal time to consume plenty of fermented foods, which contain beneficial bacteria, boasting a wide variety of health benefits. In a vaginal delivery, the baby will be “colonized” with bacteria from the mother, so it’s important to get things in shape! Coconut yogurt, kimchi, sauerkraut, and fermented vegetables are all excellent probiotic sources. Eating a diet rich in plant foods provides prebiotic fiber, which this beneficial bacteria needs to thrive.
Plants: Vegetables, fruit, nuts, seeds, and legumes are loaded with the micronutrients and fiber that pregnant women need increased quantities of. Folate, magnesium, and vitamin C are examples of nutrients that are found predominantly in plant foods.
Fluids: The need for fluids rises rapidly in pregnancy, starting even before an expecting mother is “showing”. Blood volume increases, and the body creates amniotic fluid to surround the baby. Moms-to-be may find themselves incredibly parched or waking up in the middle of the night from thirst and should make sure to get extra liquid from water, vegetable juice, and herbal teas. (To avoid waking to pee several times throughout the night, taper down the liquid consumption a few hours before bed.) Consuming enough electrolytes, especially from unprocessed salt (Himalayan or Celtic are good options), helps to maintain proper hydration.
Dates: I have to throw in this note on dates because I find it so fascinating! There is evidence to show that date consumption for at least four weeks prior to delivery can improve labor outcomes. Women who consumed six dates per day required less intervention and a quickened delivery compared to those who ate none.
Many other nutrients deserve to be mentioned here, but eating a well-rounded diet, based in vegetables, with healthy fat sources, spices, well sourced animal products (or appropriate supplementation), fruit, and fermented foods in addition to taking a prenatal vitamin that contains folate, DHA, and vitamin D, getting sun exposure, and drinking plenty of fluids should cover a woman’s pregnancy needs. If an expecting mom is worried about her diet, I strongly suggest she meet with a dietitian to discuss these fears and put together a personalized plan.
3. Why is it important to eat well postpartum?
It wasn’t until I became pregnant that I realized how under-appreciated the importance of postpartum nutrition is. Throughout the prenatal period, maternal care is of top priority, but immediately after birth, that attention seems to be shifted entirely to the child. Even the smoothest delivery puts a tremendous amount of strain on a woman’s body (a doula I know equivocates labor to running three back-to-back marathons), and even common complications can lead to surgeries in addition to emotional and physical stress. After birth a mother needs to make a priority of healing while also caring for her child. Eating the right foods, eating enough (especially if breastfeeding), and sleeping whenever possible are key to recovery. In fact, for at least the first few weeks, a mother’s schedule should mirror that of her child — eat, feed, and sleep. This is not the time to care if the kitchen is a mess or if laundry piles up. It’s the time to take advantage of any help or service that reduces the burden of day-to-day tasks. Many women, especially those with other young children, push themselves to return to “normal” too soon, which only extends the amount of time it takes to recover fully. Additionally, the societal pressure to quickly return to pre-pregnancy weight means that many women are reducing caloric intake while also breastfeeding, which can burn up to 500–800 calories per day. Focusing on the quality of food instead of calories, and eating when hungry (which may be frequently), should lead to a gradual weight loss, while providing the nourishment a woman needs for her body to heal.
4. What foods do you recommend to boost energy levels without caffeine/sugar?
In the process of attempting to get pregnant, I weaned myself off a very severe caffeinated coffee addition, and though it was difficult at the time, I now feel that my energy and anxiety levels are much more stable. Surprisingly, there are well supported benefits to coffee consumption, so I am not against coffee or caffeine per se, however, if stress, anxiety, insomnia, or poor energy are issues, it could be worth cutting out caffeine and watching out for any improvements.
During pregnancy, it’s advised to consume no more than 200mg of caffeine — equal to 12 ounces of coffee. This can be particularly difficult during the first trimester, when fatigue is common. Added or excessive sugar consumption is also not advised during pregnancy, as these foods do not provide quality nutrition and because blood sugar is less well controlled during this time.
The best ways to achieve stable energy levels are through balanced meals, plenty of sleep, and reducing stress. Balancing meals involves making sure that foods contain fat, protein, carbohydrates, and fiber so that blood sugar levels are stabilized and one can stay full until the next meal or snack. During pregnancy, getting adequate sleep may require adding a nap (when possible) or being in bed for more hours than pre-pregnancy. Reducing stress could involve taking unnecessary tasks off the to-do list, outsourcing help, shifting exercise to walking or prenatal yoga, or taking up a meditation practice. (I’ve loved the Expectful app during pregnancy!)
5. Has Thistle been helpful during this time for you?
As a dietitian/nutritionist I at least have a sense of how I would like to be eating on a daily or weekly basis, which includes a wide variety of vegetables and fruit, nuts and seeds, and moderate amounts of well sourced animal products. During pregnancy, there is an additional pressure to eat healthfully, which can often lead to unwarranted stress. The problem I regularly encounter is that it is impossible to achieve optimal levels of nutrient variety when I’m buying and preparing food myself. In order to obtain the diversity of a week of Thistle meals, I would have to buy ridiculous quantities of produce, which would require several hours of prep and would almost certainly result in waste. I also typically find myself falling into predictable meal patterns, which incorporate healthy food but are quite limited in variety. One of my favorite things about Thistle is the assortment of nutrients — several types of seeds, vegetables, and spices are present each day.
The other benefit I quickly noticed when receiving Thistle meals was improved mental health related to food planning. I felt completely content with the nutrient density and sourcing quality of each meal and loved not having to put mental effort into what I would be eating everyday. A common phenomenon in pregnancy, (which science has yet to confirm or deny) is “baby brain”, where mothers feel more forgetful or less mentally sharp than before pregnancy. There are a few theories as to why this may be true, and one prevailing idea is that expecting mothers have so much on their minds prior to giving birth — from the logistical to the emotional — that it can be hard to keep track of everything else. I’ve certainly experienced this phenomenon over the past few months, and eating Thistle meals has allowed me to avoid the decision fatigue associated with meal planning and make some mental space for more important tasks.
6. Would you recommend Thistle to other pregnant women?
Absolutely! Receiving balanced, plant-based meals is incredibly relieving mentally as well as providing excellent nutrition for a mom-to-be.
7. Are there specific foods you are avoiding while pregnant? Why?
During pregnancy I’ve been more diligent about avoiding foods that I attempted to abstain from pre-pregnancy. Admittedly, my diet is not perfect, but I try to stay away from non-organic produce as well as foods that cause inflammation, such as processed vegetable oils, refined sugar, and gluten. Though dairy is inflammatory for a large percentage of people, I seem to be able to tolerate aged or fermented dairy as well as goat milk products, so these have remained in my diet. Even the healthiest pregnancy comes with an increase in inflammation, but avoiding these food triggers can help to keep the inflammation from becoming excessive. Focusing my attention on which foods to include more of, such as a rich variety of vegetables, fruit (more than I ate pre-pregnancy), nuts and seeds, pastured eggs, and well sourced fish and animal proteins has prevented me from feeling restricted.
Of the typical pregnancy diet “don’ts”, I’ve avoided alcohol (though I have included kombucha, which contains a small amount of alcohol) and raw fish or animal proteins. The list of foods that pregnant women are encouraged to avoid are based on the likelihood that these foods could cause foodborne illness, or in the case of alcohol, cause damage to the fetus. However, for each of these items, women should feel comfortable asking questions and doing a personal risk/benefit analysis. For example, raw juice is typically discouraged during pregnancy, but I have continued to include it in my diet when I feel that it is coming from a hygienic establishment.
8. Which foods/lifestyle recommendations do you have for people who are experiencing morning sickness?
I was lucky to only suffer a mild nausea from about week 6 to 12 of my pregnancy, and never did it interfere with my ability to eat! Although, I had no appetite for the foods I typically ate on a regular basis. Plain water was repulsive, and most savory foods sounded unappealing. (I ate a LOT of carbs to get through those weeks!) I have great sympathy for women with severe nausea/vomiting because even my mild symptoms were enough to make me feel guilty for not eating the healthy diet I had planned for pregnancy.
A few tips can be helpful for managing morning sickness, but some women may feel chronically ill despite their best efforts.
1 — Add sliced fruit, a splash of juice, or essential oils to cold water to make it easier to tolerate. Sparkling water or club soda may be especially appealing for these mixtures. (Later in pregnancy, my favorite afternoon pick-me-up was a big glass of sparkling water with a hit of Thistle juice.)
2 — Take prenatal vitamins and other supplements in the evening, ideally after a meal.
3 — Find a tolerable protein source. I was completely turned off by animal proteins throughout my first trimester and opted for nut butters, seeds, and legumes instead.
4 — Eat every two-three hours. It’s counterintuitive, but eating frequently — even if not feeling hungry — can help to diminish nausea by balancing blood sugar levels.
5 — Have a bit of natural sugar before eating. Having a piece of fruit or a sip of juice can decrease nausea and increase appetite so that one may be able to tolerate a more nutrient dense meal.
6 — Ginger is an amazing remedy for stomach upset, with evidence to support that it can aid in the management of morning sickness. The Thistle ginger shots could be mixed with hot water and honey for a ginger tea, added to a smoothie, or sipped from the bottle.
7 — Get some fresh air. Weather permitting, between meals, slip outside for a short walk. Moderate exercise can help to balance blood sugar levels and fresh air seems to be particularly invigorating.
8 — Don’t feel guilty! Take prenatal vitamins on a daily basis, and make hydration a priority. Eat a healthy diet prior to pregnancy and get back to it when possible. You will not be harming your baby if you have to eat toast for a few weeks.
9. How much weight on average is healthy for someone to gain while pregnant?
When my grandma was expecting her first children in the 1950s, women of healthy weight were encouraged to gain as little as ten pounds throughout pregnancy, a feat which was often aided by diet pills! (Some studies suggest that this severe prenatal weight restriction may have promoted obesity in these babies later in life.) Medical recommendations have changed significantly over the past 70 years, and a woman of healthy preconception weight is now prompted to gain between 25 and 35 pounds. (If women are underweight or overweight prior to pregnancy, the recommendations are adjusted accordingly.)
It’s important to keep an eye on pregnancy weight gain for a few reasons. Excessive weight gain can cause gestational diabetes, which poses health risks to the baby and increases the risk for type 2 diabetes in the mother. Gaining too much weight can also increase the risk for being overweight or obese, with the associated health implications, after the baby is born. And very importantly, a sudden and severe increase in weight can be a sign of preeclampsia, which is a pregnancy complication that should be monitored carefully.
With all this said, sometimes it can be perfectly healthy for a woman to gain more than the recommended 35 pounds. (I have eight weeks left in my pregnancy and am on track to gain more!) If an expecting mother is using pregnancy as an excuse to eat ice-cream and processed foods — that’s a problem. However, if a woman is eating healthy foods, not indulging in sweets or eating excessive amounts, and eating when legitimately hungry, and through the course of her pregnancy gains even as much as 50 pounds, this may not be anything to worry about. It’s also important to note that weight gain may not happen linearly, despite the one to two pound per week recommendations that are often advised. As my midwife explained, sometimes babies go through growth spurts, when the mother may find herself hungrier and eating more than normal. This may be followed by a plateau or a reduced rate of growth in the following weeks and is perfectly normal.
I felt that pregnancy blood sugar control was a more important metric for my and my baby’s health than weight alone, so I opted to test my blood sugar for a week instead of taking the standard glucose tolerance test. (This is an important test for gestational diabetes, where an expecting mother drinks a prescribed sugary beverage, and depending on the hospital’s protocol, will have her blood sugar checked at the end of an hour or once an hour for three hours. Some hospitals have alternative regimens that require eating something along the lines of toast and eggs before the test. I’d encourage every woman to ask about her options, especially if she does not regularly include refined sugars in her diet.) Testing my blood sugar — using finger pricks and a glucose monitor — was not fun, but it gave me the ability to see how my body reacted to the foods I actually eat on a regular basis. I fully appreciate that this may not be a route that many people want to take, but for those who have anxiety surrounding the glucose tolerance test or are curious about their typical blood sugar levels, it’s a good option to know about that my doctors were more than supportive of.
10. Would you recommend different diets for those who are breastfeeding versus using formula? How do you feel about one over the other?
Breastmilk is the gold standard for infant nutrition, regardless of a mother’s diet, and breastfeeding also confers benefits to the mother, such as weight management, uterus recovery, and a lower risk of postpartum depression. That said, not every mother is able to breastfeed, for either logistical or health reasons, and this is nothing to feel guilty about. Plenty of perfectly healthy children and adults were formula fed, and it’s possible to make or procure formula with higher quality nutrients than the ones typically found on store shelves. I have always planned to breastfeed and am willing to put in whatever work is required to make it happen, but I have two of the diagnoses associated with breastfeeding difficulties — PCOS and hypothyroidism — and am not positive that it will be an option.
A woman who is unable or opts out of breastfeeding for other reasons should take some time to recover from delivery, continue prenatal supplements, and return to her healthy pre-pregnancy diet. A breastfeeding mother, however, has heightened nutritional needs beyond what was required during pregnancy. She’ll likely be ravenous and constantly thirsty, as breastfeeding burns an additional 500–800 calories per day and depletes fluid stores. She should quell these cravings by eating a nutrient rich diet and drinking plenty of liquid.
Certain nutrients in breastmilk are unaffected by the mother’s intake. Functioning as a survival mechanism for the infant, the mother’s stores of these nutrients will be depleted and syphoned into her milk. Other nutrients, however, with important roles in infant development, such as B vitamins, A, D, K, choline, selenium, and iodine are directly impacted by the mother’s diet. This is why it is important for a breastfeeding mom to not only eat enough but to focus on achieving a well rounded diet, and include supplements where necessary.
11. We know that c-sections often take longer to recover from. What are your top three recommendations for mom’s who’ve had a c-section? How can they use food to heal?
1 — Rest: All moms recovering from labor and delivery need to get adequate rest, and this is particularly true following a c-section. The average recovery time from a c-section is about six weeks, but many new mothers are eager to take on their regular tasks and care for their babies fully. The best way to recover from this major surgery is to sleep and practice self-care as much as possible.
2 — Enlist help: This is the time to allow spouses, partners, family members, friends, or hired help take care of day-to-day tasks, such as laundry, cooking, cleaning, and child care. New moms recovering from a c-section will have more than enough on their plates while caring for themselves and their babies. This can be a perfect opportunity to use a meal delivery service, such as Thistle, to eliminate the need for grocery shopping and meal planning.
3 — Eat a high protein, nutrient rich, anti-inflammatory diet: While I typically tout a moderate protein diet, wound healing is an exception, when the body needs higher levels of nutrients. It’s important to get extra calories, protein, vitamin A, vitamin C, and zinc at this time. An anti-inflammatory diet, rich in plant foods, spices, healthy fats, and well sourced animal products can also aid in recovery. Warm foods, such as soups and stews may be especially comforting following surgery, and those made with bone broth provide gelatin, which assists in the repair of connective tissue. Eating plenty of leafy green vegetables, chia and flax seeds, in addition to consuming fruit or vegetable juice, water, and herbal tea can aid in managing the constipation that is associated with pain killing medications. Fermented foods, such as coconut yogurt and sauerkraut provide probiotics to replenish the microbiome, as antibiotics are commonly administered during surgeries.
12. Have you had any crazy cravings during pregnancy?
My strongest craving, which started early in pregnancy and has not let up, is for dried mango. Not chocolate, not ice cream, not pickles, but dried organic mango that I eat by the tub-full on a weekly basis. I wish I could write it off as a health food, but even the unsweetened version I buy is loaded with sugar. Oh well. This baby is at least one quarter mango!
13. Have you enjoyed being pregnant?
For as long as I can remember, I have looked forward to having kids, but I never looked forward to pregnancy. I thought of it as an uncomfortable, debilitating hoop to jump through in order to have a family. Thus, I have been shocked by how much I’ve enjoyed this process. Luckily, I’ve had a pretty easy pregnancy — no terrible morning sickness, no sleep issues (yet), no swelling. (I’m sure I would feel differently if my symptoms were more severe.) For the most part, I’ve found that pregnancy is a great excuse to be myself freely!
There seems to be an unwritten rule that a pregnant woman can adjust her undergarments in public. “Hanger” and having a robust appetite are socially respected. I love going to bed early and take as many naps as I possibly can. And, I’ve found that “hormones” can be a great excuse for a little occasional sass.