Functional Maternity with Dr. Sarah Thompson: Rational Wellness Podcast 262
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Dr. Sarah Thompson discusses Functional Maternity with Dr. Ben Weitz at the Functional Medicine Discussion Group meeting on May 26, 2022.
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4:25 Dr. Thompson believes that in pregnancy care, there is so much focus on the health of the baby that the care of the mother gets lost. If the mother is healthy, is she’s functioning correctly, then the baby will be healthy. If the mother is not healthy, then you don’t have a healthy baby and you have a mom that’s going to struggle for years postpartum with complications because her child birth and her pregnancy experience were not functional.
6:23 One of the biggest factors if you are struggling to get pregnant is nutrition and what the mother and father are consuming prior to conception. Dr. Thompson has seen women come to her who are having trouble getting pregnant or have irregular menstrual patterns who have a history of yo-yo dieting that has shocked the system. They often have nutritional deficiencies, esp. fat soluble vitamin deficiencies like vitamin D and K, and who are over exercising. Some of these women are runners or bodybuilders. She will run a day three fertility panel, where I’ll look at AMH, FSH, LH, usually an estrogen on a day three, DHEA, as well as thyroid and vitamin D. You will often see that LH is not elevated, FSH is higher than LH, and AMH is elevated, as well as lower estrogen and progesterone levels. Dr. Thompson noted that she will also use a DUTCH test for hormone metabolites. She may also test homocysteine, B12, and folate levels and deficiencies and insufficiencies make it more likely that women may have complications during pregnancy such as preeclampsia and migraines.
15:27 Prenatal vitamins. Seeking Health is Dr. Thompson’s favorite preconception, prenatal vitamin. There is no prenatal that hits everything that a mother needs throughout gestation, because a prenatal is technically designed to grow a baby, not a mom. Our goal is to grow moms. During the first trimester, if the mother is too nauseous to swallow a prenatal, that is ok. Nausea and morning sickness is usually related to a lack of carbohydrates, so she will tend to recommend a higher fruit diet during the first trimester.
18:24 Vitamin D. Dr. Thompson often recommends a liquid D that has a lemon flavor. But if they are too nauseous to take the D, if they had good levels going in, it should be ok and they can pick up the supplementation again after week 12.
19:06 Fish oil. She does recommend fish oil, but she is not a fan of isolated DHA supplements in pregnancy because DHA can’t get into the fetal brain without EPA and DHA can thin the blood out too much.
20:43 Prenatals more. Besides the Seeking Health prenatal, there is one called Needed, which has a powdered prenatal that is one of the few that has the correct amount of vitamin D, which is 4000 IU. It also includes choline. Klaire Prenatal and Nursing Formula and Designs for Health and Thorne’s Basic Prenatal are all good. Metagenics has Plus One that includes L-carnitine and L-carnitine is especially important in the third trimester. L-carnitine becomes especially important in the third trimester because metabolism changes. The placenta produces lactogens, which block insulin’s ability to pull sugar into the maternal blood cells and when that happens the maternal physiology starts to break down fat into energy in the Kreb’s cycle. When HCG is produced, it increases the production of insulin up to 15 times pre-pregnancy levels. This insulin binds to sugar in the bloodstream and takes it to the placenta. It also stores sugar as bodyfat, which it will then break down in the third trimester as fuel for mom as glucose goes to the baby. This is why the mom should gain some fat during the first trimester to be broken down later.
42:14 Pregnant women should get approximately 1000 mg of calcium in their diet from food preferably and supplements. It is not clear what the optimal level of magnesium is for pregnancy, but clearly the RDA of 350 mg is much too low and magnesium becomes especially important during the third trimester.
46:51 Preparation for Childbirth. Preparation for childbirth starts at 24, 28 weeks, which is when maternal physiology starts to change. At this point, our baby’s adrenal glands are large, the size of kidneys, and they produce large amounts of cortisol and DHEA. These levels start to come back by 36 weeks. Cortisol helps with lung development and helps to mature the baby. Cortisol also irritates the placenta and makes the placenta signal the maternal hypothalamus to produce more cortisol. Throughout pregnancy there is a 500% increase in cortisol. The rise in maternal DHEA does mitigates this to some extent. We also see a rise in progesterone levels. Cortisol helps to remodel the cervix and make the collagen fibers of the cervix organized and parallel. Cortisol also signals the production of oxytocin on the inside of the uterus, which is the primary driver of Braxton Hicks contractions. The placenta converts the DHEA into estrogen, so all the estrogen that you find in the maternal bloodwork isn’t even hers. And the progesterone that you see is from the placenta. Estrogen has a lot of jobs and there is a fourth type of estrogen that is a mystery as to what it actually does. Estrogen also increases the gap junctions in the muscles and it increases magnesium absorption and transport. And estrogen stimulates oxytocin receptors on the outside of the uterus.
Dr. Sarah Thompson is the founder of Sacred Vessel Acupuncture & Functional Medicine, the creator of the website www.functionalmaternity.com, and the writer of Functional Maternity Using Functional Medicine and Nutrition to Improve Pregnancy and Childbirth Outcomes. She is a certified functional medicine practitioner, licensed acupuncturist, board-certified herbalist, birth doula, and educator with a passion for pregnancy care.
Dr. Ben Weitz is available for Functional Nutrition consultations specializing in Functional Gastrointestinal Disorders like IBS/SIBO and Reflux and also specializing in Cardiometabolic Risk Factors like elevated lipids, high blood sugar, and high blood pressure and also weight loss and also athletic performance, as well as sports chiropractic work by calling his Santa Monica office 310-395-3111. Dr. Weitz is also available for video or phone consultations.
Dr. Weitz: Hey, this is Dr. Ben Weitz host of the Rational Wellness podcast. I talk to the leading health and nutrition experts and researchers in the field to bring you the latest in cutting edge health information. Subscribe to the Rational Wellness podcast for weekly updates. To learn more, check out my website, DrWeitz.com. Thanks for joining me. Let’s jump into the podcast.
Welcome to the functional medicine discussion group meeting tonight on functional maternity with Dr. Sarah Thompson. You’ll really love her because she’s really awesome. She really knows this topic. I’m Dr. Ben Weitz. I’ll start by making some introductory remarks. I’ll introduce our sponsor, and then I’ll introduce our speaker for this evening. I encourage each of you to participate and ask questions by typing in your question in the chat box. Then I’ll either call on you or ask Dr. Thompson your question when it’s appropriate. Thank you for joining our functional medicine monthly meeting. I hope you consider attending some of our future events. June 23rd is our next meeting. We’ll have Dr. Ali Rezai. He’ll be giving us an update on SIBO with some new exciting research that he’s been doing with Dr. Pimentel. Him and Dr. Pimentel also just co-wrote a book about SIBO, titled The Microbiome Connection. The next meeting after that will be July 28th, but we’re still working on a speaker.
If you are not aware, we also have a closed Facebook page, the functional medicine discussion group of Santa Monica that you should just join so we can continue the conversation when this evening is over. I’m recording this event. I’ll include it in my weekly Rational Wellness podcast, which you can subscribe to on Apple podcast, Spotify, YouTube. If you’ve listened to the Rational Wellness podcast, please give me a ratings and review on Apple podcasts.
I’m very happy that our sponsor for this evening is Integrative Therapeutics. Integrative Therapeutics is one of the few professional companies product lines that we carry in our office. They have a number of really great products. One product I’d like to highlight, even though it’s not necessarily related to pregnancy that we’ve been using a lot more in the office is their specialized, highly absorbable form of curcumin, which is called Theracurmin. There’s been a number of peer-reviewed studies published using this particular formulation. It’s very highly absorbable. It’s an award of soluble form. One of the great things is two capsules a day is the therapeutic dosage.
Now I’d like to introduce our speaker, Dr. Sarah Thompson. She’s the founder of Sacred Vessel Acupuncture and Functional Medicine, the creator of functionalmaternity.com, and the writer of Functional Maternity, subtitle, Using Functional Medicine and Nutrition to Improve Pregnancy and Childbirth Outcomes. She’s a certified functional medicine practitioner, licensed acupuncturist, board certified herbalist, birth doula and education educator with a passion for pregnancy care. Dr. Thompson, thank you so much for joining us tonight.
Dr. Thompson: Thank you, Dr. Weitz, for having me here tonight.
Dr. Weitz: Great. How should we start?
Dr. Thompson: Well, we’re here because I am a functional medicine practitioner who specializes in pregnancy and maternity care. I’m going to hopefully touch base a little bit on just a small part of the functional medicine world as it applies to pregnancy care. One of the things I always try to tell people who are functional medicine practitioners who are going to be working with pregnant patients, is that everything you’ve learned about functional medicine so far, throw it out the window, because it doesn’t apply to pregnancy. Pregnancy functional medicine is its own unique doctrine, simply because you’re not dealing with one person’s biophysiology. It’s two. It changes the game. We’re going to dive into a little bit of that today.
Dr. Weitz: One of the things I love about your approach is you’re really concerned about putting the importance of the mother back into the equation, because so much of care related to pregnancy is about the baby. I know you’re a big believer that if the mother’s healthy, the baby will be healthy.
Dr. Thompson: Yes. I feel like the mother has gotten lost in the care of pregnancy. We focus so much on healthy baby, healthy baby, healthy baby, and monitoring and preventing complications that we lose the mother in that process. When we’re looking at nutrition and functional medicine in maternity care, it’s just that. It’s maternity care. It’s care of the mother. How is the mother’s body physiology changing in this moment? How do we support that? How do we protect her from these changes? Because if she’s functioning correctly, baby’s going to be fine. Baby’s going to grow. Everything is going to be the way it’s supposed to be. But if she’s not, you don’t have a healthy baby, you have a mom that’s going to struggle for years postpartum with complications because her child birth and her pregnancy experience were not functional.
Dr. Weitz: When you are approached by a woman who’s trying to get pregnant, how long before she gets pregnant would you ideally like to start working with her?
Dr. Thompson: Yeah. In my practice, we consider pregnancy a year before conception, up to a year postpartum, because there’s so much that happens preconception that sets the stage for the predisposition to complications during pregnancy. There’s so much in pregnancy that happens that then predisposes a woman to having complications postpartum that then can follow her for the rest of her life. That’s the timeframe in which when I say functional medicine for maternity care, that’s the frame we’re looking at, not just once she’s conceived.
Dr. Weitz: What do you think are some of the biggest obstacles that you often see with women trying to get pregnant?
Dr. Thompson: Trying to get pregnant?
Dr. Weitz: Yeah.
Dr. Thompson: Oh gosh. As functional medicine practitioners, we’ll preach it till the end, nutrition, nutrition, nutrition. There’s an element of fertility that we can affect. It has to do with that. What she’s consuming, what her partner, or the donor, or whatever experience we’re having here, is contributing to that conception. A lot of pregnancy complications begin at conception. It has to do with those initial trophoblast cells in embryonic development and what they brought to the table. What they brought to the table came from both sides of the party. That’s an element that we can adjust to some degree, but there’s also an element we can’t because, as I think we all are aware, women are born with all the eggs they’ll ever have. These eggs develop while she is in utero in her mother, therefore, the pregnancy experience that her mother had, and the preconception nutrition that her mother had, is affecting her fertility. We can’t change that, but we can set up the woman who is in our office with better support so that hopefully she goes into this pregnancy, or this conception, with the least amount of complications, as we support those eggs, however they came to her, and we give her the best we can so that the next generation, if it happens to be a daughter, has the best start in fertility for the next generation.
Dr. Weitz: What do you think is some of the most important factors to increase the likelihood of getting pregnant?
Dr. Thompson: Yeah. One of the things that I have seen, I think probably more commonly than I think most people are aware of is, especially in our society where we view certain looks as healthy, is for a female body, having zero body fat is not conducive to conception. The number of people who come into my office who are struggling with conception or have irregular menstrual patterns, we can almost always pinpoint some sort of history of yo-yo dieting that has shocked the system a little bit, some nutritional deficiencies because of that, fat soluble vitamin deficiencies are a big one, and over exercising. Exercise, especially intense exercise, hit workouts, CrossFit, some of these really intense workouts, they raise cortisol levels. That’s what they do.
Dr. Weitz: You tend to see lower estrogen levels.
Dr. Thompson: Exactly. Lower progesterone levels because if you’re stressed, your body’s going to do progesterone stealing. That can limit the ability of someone to conceive even if the egg in the embryo that came together is beautiful. If they can’t make enough progesterone to sustain the first weeks of pregnancy, they’re not going to conceive. It will not implant correctly.
Dr. Weitz: What sorts of hormones do you see as the most important threshold for where women need to be to get pregnant?
Dr. Thompson: What do you mean? Like levels?
Dr. Weitz: In terms of… Yeah, levels that you’re looking at when you’re trying to figure out, assessing a woman at the beginning. Let’s say somebody comes in really… She’s a runner and she’s really lean. Is that one of the things you’ll look at?
Dr. Thompson: What I will do is I’ll run a day three fertility panel, where I’ll look at AMH, FSH, LH, usually an estrogen on a day three, DHEA. If I’m doing, that’s the only panel, then of course I’m going to throw in things like thyroid, and vitamin D, and a bunch of other stuff, but the AMH, FSH, LH is a very simple test to tell us, is that person creating a dysfunctional pattern with the amount of exercise that they’re doing? A lot of people who fall into that category have missed cycles, or amenorrhea, or things like that. It’s a pretty obvious pattern, oftentimes, where it mimics PCOS as well, where they are getting cysts on their ovaries. They’re getting a lot of the symptoms of PCOS, but when you do a day three panel, that LH is not elevated, which is very interesting. FSH is higher than LH, and AMH is elevated.
Dr. Weitz: Okay. Let’s see. In terms of nutrient status, are you assessing their levels of micronutrients and making sure they don’t have any micronutrient insufficiencies? I won’t say deficiencies, obviously we have to get rid of deficiencies, but are there optimal levels of nutrients for pregnancy?
Dr. Thompson: Yeah, of course there are. Everything, again, with functional medicine, should be individualized. It’s very much, I will run testing based off of the person in the room. I will run things that… We may look at a homocysteine, we may look at B12 folate levels. Things that may indicate NTHFR, or issues with methylation that could in turn cause complications later on. We see people with those deficiencies, insufficiencies, or NTHFR, or issues with methylation, in general, are more likely to have complications in their pregnancy experience, such as preeclampsia, migraines, those sorts of things that rear their ugly head only in pregnancy. We will look at that. If somebody is… It depends on what they’re coming in for. If they’re just looking for preconception support to have the best pregnancy that they’re going to have, then yeah. I might run some basic stuff. Usually-
Dr. Weitz: For hormones, you’re always using serum? Is that right?
Dr. Thompson: Not always. We’ll use a DUTCH test.
Dr. Weitz: Oh, okay.
Dr. Thompson: Yeah, I like DUTCH. DUTCH is good. It just depends on what they’re… If they’re coming in for like irregular menstrual cycles, and things where we’re suspecting there might be an adrenal progesterone issue, or we have symptoms that are associated with elevated estrogen levels, then yeah. I might run a DUTCH test on them.
Dr. Weitz: In that regard, can you think of a case that you’ve had recently where there was an issue?
Dr. Thompson: With hormones?
Dr. Weitz: Yeah. With hormones, with irregularity, and adrenals.
Dr. Thompson: I actually was bringing up the exercise thing, particularly, because I have a patient I’ve been working with since December. She had two things. Number one, she was a bodybuilder. Number two, she’d been on birth control since she was 16 and she was now 30. Never stopped birth control at all.
Dr. Weitz: Did she take male hormones?
Dr. Thompson: Huh?
Dr. Weitz: Did she take male hormones?
Dr. Thompson: She did not. She did not. But her BMI was, I think, 15. She was pretty skinny in there. When she came off birth control hoping to conceive, she didn’t cycle, at all. She had been on… She even said the only time she’s ever cycled is when she was on birth control, where she would do the sugar pill and have a very, very mild bleeding, more brown spotting than anything. We ran labs on her and sure enough, she had functional hypothalamic amenorrhea, which is associated with people, a lot of times, who are anorexic. Same thing, where the body goes into starvation mode and it shuts down that communication from the hypothalamus for reproduction. We put her on a diet that she did not love. It’s been since December and she had her first cycle in March. It’s May and she just got a positive pregnancy test.
Dr. Weitz: Oh, wow. That’s great. What’s her current body fat level?
Dr. Thompson: She’s not happy. She did gain 15 pounds, but I told her we have to give. We did cut her workouts down, where she was working out two times a day for an hour to two hours each time. We cut her back to three times a week. Then, of course, we added some supplements in. I’ll do some things like that. We put her on-
Dr. Weitz: What supplements did you add?
Dr. Thompson: We put her on the Seeking Health Optimal Prenatal, which is one of my go-to prenatals, especially when we have some preconception issues. We did that. We did… What else did we do? Extra vitamin D. She was deficient in vitamin D. She had a vitamin D level, I think, was like 18, 19. It was pure deficiency. She’d been eating nothing but raw veggies and chicken breasts, for years, which you just don’t get much out of.
Dr. Weitz: Right.
Dr. Thompson: Right. We had some work to do. We brought her vitamin D levels up. When those vitamin D levels hit adequate levels, that’s when she had her first cycle.
Dr. Weitz: What level was that?
Dr. Thompson: When we tested it in March, it had jumped from that 18, 19 range to 35.
Dr. Weitz: Cool.
Dr. Thompson: Yeah. Not ideal, but enough to get her cycling, so that was awesome.
Dr. Weitz: Somebody asked, what prenatal vitamins? I think you just mentioned, Seeking Health. Is that right?
Dr. Thompson: Yeah. Seeking Health is my favorite preconception, prenatal vitamin. I have an article on my website, which is @functionalmaternity.com, which is basically talking about prenatals, and what to look for in prenatals, and if we get to the board here in a little bit, because when I do presentations, I don’t do PowerPoints. That’s not as personal. We’ll talk about why there isn’t a prenatal that hits everything that a mother needs throughout gestation, because a prenatal is technically designed to grow a baby, not a mom. Our goal is to grow moms.
Dr. Weitz: That’s your preconception prenatal. What about after conception?
Dr. Thompson: It depends on the trimester. First trimester, if you did all of your good homework preconception that you were supposed to, we kind of go, “It’s okay.” Do the smarty pants gummy, do whatever you can get in, because it doesn’t matter.
Dr. Weitz: Smarty pants gummy?
Dr. Thompson: Yeah. It doesn’t matter. That’s the idea, is that really, in those first 10 weeks of pregnancy, nothing she’s doing is really helping the growth of that baby. There’s going to be some things we can do to help her if she comes in deficient, but everything that goes into that pregnancy is already there. That embryo brought everything it needed for those first 10 weeks of development. That’s one of the reasons I always say… When we look at preventing preeclampsia, we’re looking preconception. If somebody had preeclampsia at a previous pregnancy, if you get to them already and they’re 12 weeks, it may be too late and you’re just going to be managing it the entire time again.
Now, can you manage it? Absolutely. We manage preeclampsia all the time and we get people to term and they have wonderful vaginal births with no eclampsia and they do great, but it’s a lot of hard work on both practitioner and patients part where prevention is easier than treatment. If we have somebody who had preeclampsia in a previous pregnancy, that year preconception, that’s where the work is going to happen, because that little embryo and those trophoblast cells that become the placenta that are dysfunctional, that’s happening in those first couple weeks. When somebody’s pregnant in the first trimester, if they can’t swallow a prenatal because it’s making them nauseous, I’m okay with that. Oftentimes, dietarily, what they actually need is more just carbohydrates and fruits. We do a high fruit based diet sometimes in the first trimester, simply because you need the sugar. That’s where I like… One of those things where, like I was saying earlier, everything you know about diet and functional medicine, throw it out the window, because right off the bat, pregnancy throws you a curve.
Dr. Weitz: Wouldn’t you want to keep that vitamin D level the same? Wouldn’t you want to keep them on that vitamin D?
Dr. Thompson: Yes. Yeah, you do, and I usually do. I have a liquid vitamin D. Oh God, I think it’s Biogenesis, is the brand, that has a lemon flavor to it, which is easier for people to keep down. But, the great thing about vitamin D is that your body stores it and uses it as it’s needed. If you come into pregnancy with adequate vitamin D levels and you’re nauseous the first trimester and you can’t keep things down, you should be able to get through that first trimester without supplementing and be okay, and pick up with your supplements at 12 weeks when that nausea kicks down, or whenever it does, and continue that journey.
Dr. Weitz: Is fish oil usually part of the program?
Dr. Thompson: Fish oils? It depends. I have a whole section in my book on fish oils because I feel like we took a little bit of the fish oil research as a country and ran with it, but missed the big picture. I am not a fan of isolated DHA supplements in pregnancy. You can read about more of it in the book, but without EPA, DHA doesn’t work correctly. It thins the blood too much. For some people, that might work. I actually have a patient right now who has a blood clotting disorder and doesn’t want to use Lovenox. I’ve never done this before this. I told her this is all experimental, but she wants to trial doing high dose DHA preconception, and testing her blood to see if it keeps it thin enough, to get off the Lovenox, because we see in the studies that’s what it does, if it doesn’t have EPA. The other thing is, why do we use DHA? We use it to help babies brain grow. That’s the idea. Well, DHA can’t even get into the fetal brain without EPA.
Dr. Weitz: Well, most of us are not just using DHA. We’re using DHA, EPA, and then topping it off with additional DHA.
Dr. Thompson: Right. We are. The majority of the world is not. The majority of midwives out there that I work with are not. They’re just giving a DHA because they saw the cool study that showed that DHA was great for brain development in baby. It’s all about baby.
Dr. Weitz: Right. If the mother is willing to take a prenatal, which one would you have them take in the first trimester?
Dr. Thompson: If they can, again, Seeking Health. They have a chewable. I’ve heard mixed reviews on the chewable from them. There’s another brand that’s called Needed. I don’t know if you guys have heard of that one, but it comes in a powder. It’s one of the only ones I have found that actually provides the adequate amount of vitamin D, which is 4,000 international units. Seeking Health did recently reformulate, so they now have 4,000 IU of vitamin D in their capsules now, which is great. But that’s a great one because it’s a powder and it’s like a milkshake. Kind of Seeking Health. They also have that protein powder. It’s a little bit lower in vitamins and minerals on the protein powder, but it helps. But needed, also, you mix it with milk and drink it down. A lot of people do good with that because it’s a smoothie. You can easily get a smoothie down when you’re nauseous.
Dr. Weitz: I’m assuming they probably have Choline in there as well?
Dr. Thompson: Yeah, yeah. Yeah. And really with Choline, we worry about Choline more in the second trimester and beyond. Again, that baby brought that Choline with him. That mom consuming Choline in the first trimester isn’t doing much for that embryo.
Dr. Weitz: Somebody asked-
Dr. Thompson: It’s helping her.
Dr. Weitz: Somebody asked about a prenatal FH pro, by Fair Haven Health.
Dr. Thompson: Ooh, I don’t know that one. I’m going to write it down right now and I’m going to look it up. If that person wants to shoot me an email later and remind me who they are, we can definitely talk about it over an email situation.
Dr. Weitz: Yeah. That’s Alison Samon.
Dr. Thompson: Hey Alison. Yeah, I know some of my patients in Australia will use… There was a brand called Naturelo that seemed to be okay that they had out there. I think I had… I’m trying to think of some of the other ones that I’ve seen that are pretty decent. Those tend to be my go-tos. Klaire.
Dr. Weitz: Somebody else suggested Designs for Health. I’ve used that on a few patients as well.
Dr. Thompson: Yeah. Let me pull that up. There’s a reason I don’t like the Designs for Health prenatal and I can’t remember off the top of my head why it is. I’d have to look at the label again and go through the listing, and be like, “That’s why I didn’t like that one,” but that’s one I typically don’t love. Like that one. But that’s one I typically don’t love. Thorne Basic Prenatal is one that I will sometimes use in first trimester, because it’s less pills. It tends to be a little bit more digestible, but it’s still not one that I’ll continue throughout the rest of pregnancy. Klaire Prenatal and Nursing Formula is another one, because it’s three pills a day, that some people do really good on, because it’s only three pills a day, that we’ll try to get in the first trimester, or get for people who can’t do Seeking Health, eight pills a day, because that’s just, I can’t do that.
Dr. Weitz: And Metagenics has one and they’ve added in their packets, L-carnitine and I looked it up and there’s actually a fair amount of research.
Dr. Thompson: Yeah. Yeah.
Dr. Weitz: Showing benefits to L-carnitine.
Dr. Thompson: So L-carnitine becomes important in the third trimester, specifically. Simply because metabolism changes in the third trimester. And what you’ll find is that the placenta produces lactogens, and these lactogens help to block insulin’s ability to pull sugar into the maternal blood cells. And when that happens, the maternal physiology starts to break down fat, right? L-carnitine is important for the breakdown of fat, at a cellular level, to make energy in the Krebs cycle. We all remember the Krebs cycle, right? And that’s where it becomes really important is we see that using L-carnitine in that third trimester helps with cellular metabolism on the maternal side, more than anything. And a lot of people, the way the maternal physiology is designed to work is that in the first trimester, the pregnant person is supposed to gain body fat. We’re supposed to crave carbohydrates in that phase, for a number of reasons, right?
When hCG is produced, it hijacks the body. And one of the things it does is it increases the production of insulin. And we can see that production of insulin hitting sometimes up to 15 times what it was pre-pregnancy. And that insulin binds to sugar in the bloodstream and takes it to the placenta, right where the placenta’s growing, it’s not quite placenta yet, to the uterus to make a placenta. And it’s also storing sugar as body fat in the maternal physiology, which it will then break down in the third trimester as fuel for mom, as glucose goes to baby. Everything in pregnancy is this aspect of preparing for preparing. And it’s a really interesting concept.
And as you start to look at all the different aspects of physiology and function and applying functional medicine, how these things work to the maternal physiology, it becomes very interesting that you have to have these different things happen, at specific phases in gestation, for the next stage to function correctly. And that’s one of them, mom has to store body fat in the first trimester. And in our society, we have a fear of weight gain, especially in pregnancy. I can’t tell you how many people I’ve worked with that they get scolded by their primary care, because they gained any weight in the first trimester. Because that baby isn’t very big and they’re like, “Oh no, you shouldn’t be gaining weight yet.” But if we look at how the body is designed to function, she’s supposed to gain a little bit of body fat in that timeframe and then break it down later.
Dr. Weitz: So, I want to touch on the insulin thing more, but just in terms of the body weight, do you have a ballpark figure of what you think is optimal? I know it varies. It depends on a lot of different factors, but maybe a range that you think is a good, healthy amount to gain first trimester, second, third?
Dr. Thompson: Yeah. I would expect somebody to gain, probably five ish pounds, maybe 10, right? Five, that maybe, 16, 18 week gestation mark, okay? Then we start to gain weight that’s baby weight and it’s a different type of weight, right? Mom should get a little thicker in her thighs. Mom should gain a little bit of boob weight. That’s all normal weight gain in that first trimester. Now, if she’s putting on 20 pounds in the first trimester, that’s a problem, right? That’s where we start to see, ooh, okay, we kind of went the other way there, right? “You maybe need to lay off the brownies,” usually. That was me, okay? That was a personal hit on myself. I jokingly call my second child the brownie baby, because that was the only thing I could keep down in the first trimester. And I, looking back, I think pretty sure I was a magnesium deficient person coming into that. But, whole other story. It just depends. Yeah, so depending on size, like me, I’m five foot. I’m a tiny person. And I remember, with my first pregnancy, I struggled to hit the 20 pound mark. I gained a lot in the first trimester and then I kind of plateaued and gained baby weight, the rest of the timeframe, okay? And I remember my-
Dr. Weitz: So you said, “10 pounds, first trimester.” How much second? How much third?
Dr. Thompson: I don’t even look at it. I don’t weigh my patients.
Dr. Weitz: Oh, okay.
Dr. Thompson: Yeah. I don’t weigh anybody in my office, because I typically don’t believe that weight and body size equals health. Now, obviously, if they come in and they’ve gained, I mean, usually somebody who’s gaining excessive weight, you can see it, right? It’s not their normal physiology body weight growth, right? That’s a good practitioner, you look at that patient and you go, “You know what, let’s start working on some things. This is not…” Especially if you’re working with somebody and you’re really working their diet and you know they’re doing a good job right? And they’re gaining weight. That might be a sign of early Preeclampsia, that’s different.
Dr. Weitz: Let’s say your body builder patient. If she’s getting into the third trimester and she’s barely gained 10 pounds, she might be concerned about that, right?
Dr. Thompson: Yeah, absolutely, right? She’s going to feel it. Again, most of the time babies do just fine and they take what they need from mom. But she’s going to feel it and we’re going to talk about it, and we’re going to tell her, “Hey, you probably need to throw some more calories in there.” I would say, I tend to, and in my practice, it’s what I see, probably, more so, is err more on those sides of things. I’m more worried if somebody is a little too skinny, they’re not gaining the body fat or they’ve lost weight in pregnancy, that’s a problem. Versus somebody who gained a little bit more than what their physician was hoping they would gain.
Dr. Weitz: So, let’s talk, you mentioned insulin, how there’s more insulin receptors. How should we best monitor insulin and glucose, to make sure that we don’t have metabolic problems during pregnancy?
Dr. Thompson: Yeah. Well, some of that is slightly out of our control. So we could definitely do an insulin test in the first trimester and see, especially if you have patients who are like the hyperemesis side. But it becomes more just management. Honestly, usually the people who have that, like up to 15 times increase in insulin, are people who have insulin resistance or PCOS prior to preexisting diabetes. Those sorts of things, you’ll see that crazy high increase. You’ll also see it in certain genetic conditions. So we see that there are a couple of genetic genes that are associated with more hyperemesis. And hyperemesis has been basically linked to this excess production of insulin, which then causes more than anything hypoglycemia, right?
So, a lot of what happens in the first trimester, especially with nausea, is this low blood sugar issue. And really more than anything in the first trimester, if I have people who are definitely getting that hyperemesis, you could test them. But everything in pregnancy just happens so darn fast, that if they’re getting nauseous like that, and they’re struggling to keep food down, all of this, we honestly just assume they’re hypoglycemic. Because there’s a 99% chance that their blood sugars are dropping too low, due to whatever reason. And they’re having cortisol issues and whatever it is, right? And they can’t compensate for the amount of sugar that their body needs, at this time. And I always joke, it’s like this horrible design in biology, that when your blood sugar drops too low, your body wants to vomit. When it does, it’s a shock scenario, and a lot of these women who are hitting points of low blood sugar in the first trimester, they’re literally going into shock, like a borderline shock scenario. And if you talk to women, or if you’ve experienced it yourself, you know it when you get that nausea, and that’s severe nausea in the first trimester, it’s not just normal and, “I’m kind of queasy.” You are shaking and you are uncontrollably vomiting and dry heaving, and it’s a shock reaction. And it’s because that blood sugar dropped too low.
Dr. Weitz: And what do you consider the number that you’re really concerned about, as far as low blood sugar?
Dr. Thompson: I don’t even test. I go off of symptoms.
Dr. Weitz: Oh.
Dr. Thompson: If you looked at if like a fasting blood sugar on somebody in the first trimester, these are things that just never get run, honestly. I would say, probably, anything lower than 75 is probably going to cause some element of nausea. You need to keep that blood sugar up. And for a lot of these women, I had one patient in particular who had hyperemesis, this was her fifth pregnancy with me. And every one of her pregnancies she’d needed IV hydration, in the first trimester she was going in every other day, in her previous pregnancies. And the only way, and there’s an element of genetics there, right? This is something that happened in her mother’s pregnancies. And again, new studies are showing that we have a couple of different genes that are now being associated with hyperemesis and all of these genes regulate blood sugar, or regulate insulin production. So, in her case, we had her eating basically a little bit of extra sugar and she didn’t end up with gestational diabetes or anything like that. She just needed more healthy sugars in her pregnancy, because of those insulin levels. She had to compensate for it to make herself feel good.
Dr. Weitz: Dorothy asked if hyperemesis continues into second trimester?
Dr. Thompson: So, that oftentimes is associated with some of those genetics. Really cool, interesting studies too, that talk about some of that hyperemesis and some of the excessive nausea being associated with an exasperation of H. Pylori in some patients. And you’ll see that being a trigger, or a cause of some of these morning sickness patients that go past 20 weeks. Usually your blood sugar levels stabilize by 16, 18 weeks. That’s when we see a shift in the production of hCG. So, there’s alpha and beta, and all these different types of hCG and the one we typically test for beta, I always get them mixed up. And then there’s a shift usually by 16 weeks, 18 weeks max, that then decreases, that increase in insulin production.
Dr. Weitz: Let’s say instead of a bodybuilder woman, you have somebody who’s heavy and she gains a lot of weight in the first trimester. And now you’re seeing a blood sugar, say, drop. When are you concerned that this is insulin resistance?
Dr. Thompson: Yeah. And then I would probably, in that case, that’s a specific case. I would probably be concerned from day one, right? If she was already on the heavier side and then gained a lot more weight, then that might be a problem. And that’s something we need to work at. And it becomes, again, this game of kind of battling some of the maternal physiology, because again, some of it we can control, and some of it we can’t, because some of it is being controlled by the secondary person in the game. And we can’t stop the hormone productions from that embryo and that baby.
Dr. Weitz: Crystal asked, “Do you ever have them wear a continuous glucose monitor?”
Dr. Thompson: I have not. Hold on one second, I’m going to open this window and get a little more light in my room, real quick. Okay. No, I haven’t. I’ve had them do it, once we get into second trimester, and stuff like that. But it’s going to be so skewed, in that first trimester, that it’s not even worth doing. You’re going to see it all over the place, because she really is all over the place. And again, it’s sometimes easier just to go off symptoms, because it’s such a short timeframe and it’s not like we have a big… And one of the things of pregnancy that makes it, I think. Sometimes harder to work with pregnant patients is you don’t have the time, that you do with people outside of pregnancy. Everything changes within four weeks, every four weeks, it’s almost a completely different person that you’re working with. And so a lot of these tests and as I said, everything, you know about functional medicine, throw it out the window. Because, a lot of these tests that we use in patients, preconception even, don’t apply to pregnancy. It’s just, you don’t have the time. It’s always, it’s going to be inaccurate. It’s not worth doing. And so it’s learning to look at functional medicine differently, and using what you have available and what you can use and learning to analyze it. And learning to find those little nuances and symptoms that kind of give you clues as to what’s going on. It’s a lot harder than working with, again, the preconception fertility patient, either. It’s just a different game.
Dr. Weitz: What about exercise during pregnancy?
Dr. Thompson: So, exercise during pregnancy, I’m not an exercise specialist by any means, but typically it depends on the person, right? If that person has done a lot of these exercises, didn’t have any fertility issues, and wants to continue doing them during pregnancy, by all means, go for it. It’s not, when you want to start a new exercise regimen. It’s not when you want to start, “Oh, one of my friend said I should go do Cross Fit and I think I want to go do it, and I’m 16 weeks pregnant.” No, now is not the time.
Dr. Weitz: Right. But if they’ve been doing it all along, probably shouldn’t be a problem.
Dr. Thompson: Like, again, my weightlifting patient. Definitely I’ve had a couple of them. I’ve had weightlifting patients before who continue weightlifting. Again, we cut them back and we say, “You know, you’re two hours, twice a day, may not be okay right now. But by all means, it makes you feel good, go for it. If it starts to be a problem, then we’ll address it.”
Dr. Weitz: And ideally, being in shape, being fit, having strong muscles should help with pushing a baby out at the end, right?
Dr. Thompson: Yeah. That’s our goal, right? Like I said before, I mean, we’re looking at creating a functional pregnancy and childbirth. That’s the end goal. We can have a healthy pregnancy, but we need to have a healthy childbirth, as well. It’s like my book says like we’re using functional medicine and nutrition to improve pregnancy and childbirth outcomes. When you have pregnant patients in your office, what are their biggest concerns? Their biggest concerns are typically, “I want my baby to be healthy and I want to have a good labor.” Nobody comes in saying, “I want to have a crappy labor.” No, they want to have a good labor experience. They don’t want a struggle in that process. They want that baby to come out the way it’s supposed to. And they want it to be a natural experience. And to me, this is almost like my pièce de résistance, and my whole, I guess, push in the book and everything that I did research-wise, is I spent the last 15 years working with pregnant patients, being there from fertility through conception and being at their births.
And I joked that, as a birth professional, when I went to birth, I’m kind of a lazy doula. Like I don’t want to work that hard. I want my patients to have awesome, beautiful, functional births, where I can leave and high five and say, “You did that. I was just here. I was just the voice, you did that on your own.” Right? And in order to do that, nutrition became a big part of my practice and it always was, but in a different way. And it required me to do research. And the research that I started to do, was based off of, “How do I make sure my patients are having the most functional birth experience that they can, with what they’ve been given?” Now again, like before, there’s things that we control, can control in the preparation for childbirth and there’s things we can’t control. There was, I’m sure you guys all know who Dr. Weston Price was, right? Everybody knows Weston Price at this point. Anybody know who Kathleen Vaughn was?
Dr. Weitz: No.
Dr. Thompson: Kathleen Vaughn was another physician during that timeframe, and in fact, Weston Price even quotes some of her book, in his book, Nutrition and Physical Degeneration. But she was a physician who studied specifically nutrition in childbirth, in the 1930s. And her big push was that the nutrition that a child had from birth through puberty was more indicative of their ability to birth a child, than anything they did after puberty. And what she found was that it changed the pelvic shape. So, young girls who were fed a poor diet developed poor pelvic shape, and those who had a great diet had great pelvic shape.
Dr. Weitz: What does that mean, poor pelvic shape?
Dr. Thompson: So, one of the things that we see being associated with like, failure to progress and some of these increasing risks of cesarean delivery in our society, is that babies don’t fit through pelvises the way they used to, right? And that the pelvic shape changes and the pelvic opening narrows, to be a little bit more football shaped or a little mis-angled and baby’s heads can’t come through that. No matter how much awesome work a mother has done nutritionally, to prepare her body for labor and delivery. Head can’t come through in misshapen pelvis. And now this was, of course, way back in the thirties and nobody has done anything else since then. Her book was called Safe Childbirth. And apparently, as far as I know, there’s like a handful of copies left. One of them is up by me at the University of Wyoming and I did rent it one time, to read through it and it’s just a fascinating book. I love old books, because it’s just like Weston Price’s book, there’s just things you can’t replicate anymore. You can’t look at Native American society and see what happens to these people as we abuse them and pull them into, oh gosh, reservations and feed them ration food, and destroy their whole nutritional framework. You can’t do that anymore, nor would we want to.
Dr. Weitz: What are the optimal levels of calcium and magnesium that pregnant women need to be consuming, and in what form and how much from supplementation and…?
Dr. Thompson: All right, that gets tricky. So, usually it’s about a thousand milligrams of calcium is what we aim for in pregnancy. With magnesium, that one gets tricky. Simply because, hold on, I’m going to turn my lights on. My house is getting dark on me. Let’s get some lights in here. Okay. So, magnesium gets tricky because there is little to no research on what a pregnant woman needs, in magnesium, in the diet. And I would argue that the RDA is ridiculously wrong. And if you look at it, and once you understand physiology, you kind of go, “Yeah, that doesn’t make any sense.” So currently, RDA for magnesium for pregnancy is 350 milligrams. And that is nowhere near adequate, especially as we get closer to the preparation for labor and delivery. And most people don’t know actually preparing for labor and delivery doesn’t happen in that last little four weeks of pregnancy. It starts at like 24 and 28 weeks. That’s when the body starts preparing for childbirth. And everything from there, kind of stair steps. And if you miss one of those stairs, you’re going to be behind. And a big part of those stair steps is magnesium. Can we draw pictures?
Dr. Weitz: For? Yeah, go ahead.
Dr. Thompson: So I mean, if you want to keep talking about magnesium, we can, or I can tell you kind of the cascade of things that go into the functional childbirth experience, and show you all the little spots that magnesium starts to build, and why magnesium becomes so important in that third trimester. And how I personally believe that the RDA for magnesium should be almost triple, what the RDA actually says.
Dr. Weitz: Sure. But is there a form of calcium that you like for pregnant women?
Dr. Thompson: You know, oftentimes in all honesty, I’m pushing foods. I’m not pushing supplements. If we’re doing a calcium, usually what’s in a prenatal is adequate, and we just add it in, in the diet, wherever we can.
Dr. Weitz: Yeah. I mean, there are some prenatals that don’t have the calcium in there.
Dr. Thompson: That’s true. And that’s why we kind of pick the good prenatals, right? We have specific ones we want to work with, and ones we don’t want to work with.
Dr. Weitz: Right. Could you give the name of that doctor again and the book?
Dr. Thompson: Yeah. So as Kathleen Vaughan, and the book is called Safe Childbirth.
Dr. Weitz: Okay, thanks.
Dr. Thompson: Yeah, like I said, there’s a couple of universities that still have copies, but it’s out of print and the copies that they have are very, very old, or they are like photocopies of it. So, it’s not actually the book.
Dr. Weitz: Okay.
Dr. Thompson: Yeah. But it’s pretty interesting. And if you look at, and if you look at, oh gosh, Weston Price’s book, right? Nutrition and Physical Degeneration, he has quotes from her book, in there too, which are really good. And if you can’t find her book exactly, like I said, there was one at the University of Wyoming in Laramie, Wyoming that I checked out a few years ago and…[inaudible 00:46:00] that I checked out a few years ago and got to read through. And it was a photocopied version of that book. It wasn’t the actual print copy. But it’s fascinating. Another really good book is Labor Among the Primitives. And it is a book from 1880s, and it’s an OB/GYN who traveled the world basically going, “Hey, why are women in modern society dying in childbirth, where we see, quote unquote, primitive cultures doing fantastic in childbirth?” And she documented birthing posture, birthing practices in all sorts of different cultures around the world. So that’s another really good book.
Dr. Weitz: Show us your diagrams.
Dr. Thompson: Show us the diagram. Okay. So let’s go through. So like I was saying, the preparation for childbirth really starts at 24, 28 weeks. That’s when the maternal physiology starts to change. And I drew part of this diagram for Ben earlier today and it looks like a pregnant snowman, okay? So, there we go. This is my pregnant lady, okay? Let’s see. I don’t think you can get that far. Hold on, I might have to make her smaller. I don’t think you can see the whole picture, can you. Let me do this. Okay, so this is my pregnant lady. Can everybody see that okay?
Dr. Weitz: Yes.
Dr. Thompson: Everybody’s good? Okay. So let’s break this down. So everything that happens in preparation for childbirth has very little to do with the mom. It’s her reaction to what’s happening with the baby. Now, at about 24 to 28 weeks, our baby’s adrenal glands are the size of kidneys. They’re huge. And they are producing copious amounts of two very important hormones, DHEA and cortisol. These two hormones start to increase. So you can actually do serum testing for cortisol and DHEA. And as you start at 24, 28 weeks, you’ll see every week, they just raise, raise, raise, raise, raise, raise, raise, raise, raise. And then by 36 weeks, they start to come back down because things are changing there. And all of these hormones, every time we hit a little threshold in these hormones, something cool happens in the maternal physiology. And we need these things to happen from about that 28-week mark on for labor to be functional. If these things don’t happen, whether baby isn’t producing what they’re supposed to, or the placenta isn’t doing its job, or mom can’t respond to these hormonal signals, then we don’t have that functional labor experience. So both of these hormones do very, very different things in the body and they do very important things.
Cortisol starts to do things like, let’s see here, let’s go this way. So cortisol starts to do, let’s see, it helps with lung development. So it helps to mature the baby. So as baby’s adrenal glands get bigger, we make more cortisol and we get more lung development. Cortisol also irritates the placenta a little bit, and it actually makes the placenta signal the maternal hypothalamus to produce more cortisol from her adrenal glands. Just so you know, throughout pregnancy, there is a 500% increase in cortisol. That is huge. That is huge. And what happens to help mitigate that is we see a rise in maternal DHEA at the same time. We also see a rise in progesterone levels. And what that does is help to mitigate the negative effects of cortisol and estrogen as these changes start to happen in the maternal physiology. So then we have maternal cortisol that starts to do things at a cervical level. So this is the cute little cervix down here. And cortisol’s job is to start remodeling the cervix. Now, up until this timeframe, progesterone has done a really good job of taking all the collagen fibers of the cervix and wiring them together so that the fibers of the cervix are all like a nest of fibers. They’re all knotted together. And they just, they can’t come apart even if they wanted to. Cortisol’s job is to make them parallel. So from 24 to 28 weeks on, depending on the person, we start to see cortisol changing the structure of the fibers in the cervix. It actually changes the type of collagen that gets produced, which is very interesting. Cortisol also signals the production of oxytocin on the inside of the uterus. Now, oxytocin on the inside of the uterus is what’s primarily the driver of Braxton Hicks contractions. So these are contractions that don’t really hurt. Most people who Braxton Hicks are like, “Oh, look, my bellybutton’s tight.” They are contractions on the inside of the uterus. And as we get more cortisol, we get more of these internal contractions and they do several different things. They help to tone the uterus. But they also stimulate the production of receptors on the cervix for prostaglandins.
Everybody following so far? You good here? Okay. We need these receptors on the cervix for prostaglandins to do their job. Now, let’s go back over here to DHEA. So DHEA, the placenta converts DHEA into estrogen. So all the estrogen that you find in the maternal bloodwork isn’t even hers. She doesn’t make her own progesterone. It’s all fetal progesterone from the placenta, which is pretty cool. And this estrogen has a lot of jobs. We have four different types of progesterone. Most people only know of three, but there is a fourth progesterone that is only produced in pregnancy. It’s still a mystery as to what it actually does, but it is only found in the fetus in pregnancy. And it’s pretty cool. And it’s also produced by the placenta and by the fetal liver, which is pretty neat.
Dr. Weitz: I think you mean a fourth type of estrogen?
Dr. Thompson: Yes. What did I say?
Dr. Weitz: Okay. I think you said progesterone.
Dr. Thompson: Oh, oops. Estrogen. Sorry.
Dr. Weitz: Okay.
Dr. Thompson: Okay. Estrogen starts to do several things here as well, also playing with the cervix. So the first thing that ever happens in the preparation for labor is this remodeling of the cervix. And this has to happen. You have to soften that door or it can’t open. You can’t just throw contractions on a cervix that isn’t soft. If those fibers are still like this and you give them a bunch of pitocin, you’re never going to get that baby out. You’re just going to cause distress and then we’re going to have a C-section. We have to get those fibers parallel. And then what prostaglandins do is they give them flexibility. They make them wiggly. Now they can move. Now those fibers can move when we need them to, but not yet. We don’t need them to move yet. So we have prostaglandins, and it’s specifically the two series prostaglandins. So it’s PGE2 and PGF2 alpha. Those are our primary prostaglandins that we see affecting the cervix. Again, starting at that 28-week mark, we can start to see that. That’s why women will start to get things like more vaginal discharge. That’s that cervix creating fluid. Those prostaglandins then start to make things like more oxytocin. Now we’ve got a double whammy here. So we’ve got prostaglandins that are stimulating production of internal oxytocin, which then makes again more prostaglandin receptors. See, it’s like a stair stepping thing. We keep hitting these little thresholds and eventually we have more, and more, and more, and more.
Going back to estrogen. Estrogen’s doing other things in the body too. It’s going to do things like increase gap junctions in the muscles. It’s also going to increase magnesium absorption and transport. Why would we need that? We’ll get to it. It’s also going to stimulate oxytocin receptors on the outside of the uterus.
Dr. Weitz: What does increasing gap junctions in the muscles mean?
Dr. Thompson: Means it makes more areas for contraction to occur.
Dr. Weitz: Okay.
Dr. Thompson: Yeah. We need to have powerful, strong contractions in those gap junctions to help increase that ability within those muscles to have more contractibility. Okay. So then we get this little oxytocin receptor growth on the outside of the uterus thanks to estrogen as well. All right. So as we’re going here, we keep getting these cascades and cascades. And eventually we get to a point where we get so many prostaglandins that we start to make two other things that happen in these different, oh, in the prostaglandin world.
One of them is thromboxane A2. Again, nobody ever talks about that guy. It’s kind of like the series two prostaglandins’ better cousin. So it’s an anti-inflammatory. It’s also a coagulant. And actually it’s the primary coagulant of childbirth. And so when you clot, when the placenta comes out and we see clotting that happens, it’s thromboxane A2 that does the job primarily. And one of the reasons that I dislike DHA, isolated DHA supplementation in pregnancy, is that DHA neutralizes thromboxane A2 so it can’t do its job. That’s how it thins the blood and prevents clotting. And if you have thromboxane A2 production at childbirth that is supposed to be clotting as that placenta is detached, and you have just been pumping somebody full of isolated DHA their whole pregnancy, they may not clot. And we may have just increased their risk of hemorrhaging in childbirth because we didn’t do EPA with it. EPA prevents that. Following?
Dr. Weitz: Yeah.
Dr. Thompson: Okay. So that’s one of the things that these different prostaglandins do as they increase throughout that timeframe. The other thing is it helps to produce a chemical called hyaluronic acid. Everybody know what hyaluronic acid is?
Dr. Weitz: Yeah.
Dr. Thompson: Yeah. It’s the lubricant of skin and cartilage. We see a lot in skincare. It’s very popular for women to reduce their wrinkles. Well, it’s very popular in your cervix as well when you go into childbirth. So, remember our cervix, right? It started off all knotted. Then we made it parallel. Then we started to give it flexibility. And now what we’re going to do is we’re going to fill the gaps with fluid. We fill this interstitial space with fluid. And because these guys are flexible, we can now fill it with fluid, and open, and soften. And now we are effacing. Now we can have a baby. Now, what can happen is, our baby’s lungs can be fully developed. And as they fully develop, they produce these chemicals called surfactants. And surfactants are very, very inflammatory and irritating in the utero cavity. And eventually what happens is they’re so irritating on that placenta that the placenta says, “You know what? This baby is got to go.” And the placenta sends a signal to the brain that causes a production of oxytocin from the brain. Which now we have oxytocin receptors if we did everything we were supposed to. And now we have active labor.
So how does nutrition play into this? Let’s go backwards. Let’s go back to where we started. All the way back. We’ve already gotten to labor. Yay. We did all the work from 28 weeks all the way to 40-plus. Now we’re going to go backwards and we’re going to talk about how nutrition plays into this process.
Cortisol remodeling. We need to be able to allow cortisol to do its job of making these guys parallel. We don’t want it to go too fast. If we go too fast, we have preterm labor. So we need certain vitamins, specifically vitamin C and vitamin E. They help to maintain the structure of the collagen and reduce inflammation and oxidative stress during this process. Everything in pregnancy is highly, highly inflammatory. Everything that’s happening here is inflammation. And your body, the pregnant person’s body, is trying to mitigate this inflammation all the way until the bitter end.
Progesterone is something that never gets tested in pregnancy outside of the first trimester with the fear of miscarriage. And I really wish we tested it in the third trimester, simply because we see that lower progesterone levels are associated with more pregnancy and childbirth outcomes in the third trimester. And nobody ever tests it. And it’s really interesting to me because we need progesterone. And a lot of the things that happen with low progesterone are also mimicking of vitamin D deficiency. And it’s because you need progesterone to make vitamin D receptors in the placenta for vitamin D to do its job. And if you have low progesterone, you could be taking all the vitamin D in the world, you can’t bind it into the placenta to do its job because there’s no receptors. There’s very little receptors. And so it’s something that I really, I like to do. I usually at 28 to 32 weeks will test progesterone levels. And you want that between 100 and 300 mgs. That’s a lot, right? In the first trimester, we’re lucky if we’re like, “Yes, 25.” That’s our magic number. By the third trimester, we’re sometimes hitting 300. And we need that progesterone to prevent preterm labor. We didn’t throw thyroid in here yet, but I’m going to throw some thyroid up here in a second too.
Prostaglandins. Making of prostaglandins. We need fats, and we need omega-6 fatty acids. Prostaglandins are made from specifically things like linoleic acid, found primarily in nuts and seeds and meats. And we need that to make prostaglandins. Most people do fine in omega-6 fatty acids. That’s typically not something we see deficient in the standard American diet and with most people we see, unless they’re eating a low fat diet or they’re overdoing their omega-3 fatty acids. Those are timeframes where you may not see that production the way we’re supposed to. But typically people do pretty well. And I just say, make sure you’re getting a serving of nuts and seeds every day, somewhere in there.
Dr. Weitz: By the way, you mentioned if progesterone’s low, is there a natural way to help progesterone?
Dr. Thompson: Not at that phase. It becomes medication based.
Dr. Weitz: Okay.
Dr. Thompson: Yeah. Again, sometimes in pregnancy prevention is easier than treatment. And that’s one of those scenarios where if the body isn’t producing progesterone. Sometimes I’ve seen some things that talk about using vitamin E in high doses to increase progesterone production, but not in pregnancy. The fear there would be thinning of the blood and some issues there.
Dr. Weitz: Yeah. I mean, it sounds like it probably wouldn’t be appropriate, but we tend to use chasteberry vitex.
Dr. Thompson: Yeah. And I don’t know if chasteberry would be as effective to bring those levels up in that timeframe.
Dr. Weitz: I doubt it. There’s no way it’s going to be as effective as taking progesterone.
Dr. Thompson: Yeah. That becomes definitely acute crisis management. And it’s better just to get the progesterone suppositories and support it that way. And it’s interesting, because sometimes we’ll see too, like anxiety, depression, and some of those sorts of things that rear their ugly heads in the third trimester, you can oftentimes find low progesterone and low DHEA in those scenarios. And what’s happening is mom is feeling that 500% increase in cortisol. And she shouldn’t be feeling it. And so sometimes, like I have a patient right now who has been struggling with anxiety and we tested her progesterone. And sure enough, her progesterone is silly low. And that’s what we’ve done is get her midwife to give her some progesterone suppositories. And within a week, her anxiety was gone and she was sleeping through the night. And it was low progesterone. And who knows how she got there. It was an IVF pregnancy. And sometimes we’ll see IVF pregnancies are prone to having some of these different issues. Maybe it was that. Maybe it was just, she’s an older mom. Who knows? Maybe it could have been just bad luck. But using that progesterone in an acute crisis management situation helped her symptoms. So that’s part of functional medicine. Sometimes we need the meds. Sometimes we need that. And in that case, that’s what we needed.
So the other thing we’re getting here is this production of oxytocin. Now, oxytocin is a protein, amino acid-based chemical. And it’s made from nine amino acids. And two of those amino acids are essential amino acids, meaning she has to consume them in the diet or she can’t make her oxytocin to save her life. And those are primarily, let’s see, leucine and isoleucine. Those two have to come from the diet. Eggs, eggs, eggs, eggs, eggs. I love my pregnant mamas to be eating eggs every single day. The more the merrier. Eggs have everything you know to grow a baby. And everything you need to help a mom function. Unless she has an allergy to eggs. Then we find other methods. So you need those.
The other thing you need is for oxytocin to do its job, you need magnesium. So from 28 weeks on, we start to see this interesting increase in the need for magnesium down here. We already talked about estrogen here. He upregulates the absorption and the transport of magnesium throughout the body. It pulls it into the uterus. It pulls it into these tissues. Partly because oxytocin needs magnesium to bind to its receptor. If there’s no magnesium in there, it can’t attach to that receptor. It can’t do its job. And therefore, we don’t get the contractions. And if we don’t get that happening, then we don’t get the receptors on the cervix that prostaglandins need to do the softening. We want the squishy cervix. We can’t do that without magnesium.
All right. Other things we need here. We need to make these oxytocin receptors on the outside of the uterus. We need several things for this to happen. Number one, we need cholesterol interestingly. Typically, oxytocin receptors do not have a very long lifespan. Couple days, they’re gone. We need these guys to stick around for a while. And so cholesterol, in this specific scenario it’s very interesting. Cholesterol becomes part of the makeup of these oxytocin receptors and it keeps them alive longer. And what’s interesting is as cortisol levels rise throughout pregnancy, we also see that blood cholesterol levels also rise. If you take a third-trimester lipid panel, it doesn’t look very good if you’re not pregnant. LDL is elevated. Triglycerides are through the roof. It doesn’t look good. And nobody ever runs them. But low cholesterol in the third trimester may be a sign of labor and delivery complications. Because you have to have that cholesterol to keep that oxytocin receptor in place longer so that it’s there. And we accumulate tons of oxytocin receptors for the big day.
Everybody following still? Okay. The other thing we need here is vitamin A. And not just any old vitamin A, we need retinoic acid. You can’t make an oxytocin receptor without retinoic acid. And we have a little bit of a war against vitamin A in the diet of pregnancy. And no, we don’t, but in general, people are afraid to consume things like liver. People are afraid to consume these food sources that are high in vitamin A. There is a six-fold increase in vitamin A receptors in the uterus in the third trimester, because you need vitamin A to make these oxytocin receptors. Now, retinoic acid is one of the many forms. We have retinol, retinol. We have, and retinoic acid. Those are the animal-based vitamin As.
And then we have the carotenoids, the beta-carotenes that can be converted into retinoic acid. Now, beta-carotene can only be converted into retinoic acid if you have adequate amounts of T4. You have to have thyroid hormones, and specifically T4, not T3, to make the conversion of beta-carotene to retinoic acid. And even then, it’s only a 15% conversion rate. Now, I have a study sitting on my desk from February, March 2022 that is really cool. And it’s talking about thyroid in the third trimester and how subclinical hypothyroidism is associated with more labor and delivery complications. Now, why? They don’t know, but could it be this? Maybe, right? Maybe people who have subclinical hypothyroidism can’t make the oxytocin receptors that they’re supposed to. Maybe there’s something there, but you do see in these studies, that people who have subclinical, meaning their TSH is less than a 2.5 in the third trimester, this is what the study said, are more likely to have a delay in the onset of labor, increased cesarean rates, and more risk of hemorrhaging during childbirth. I know I talked in an… I don’t know if it was with you Ben or with a different podcast, but we talked about thyroid and how the Endocrine Society is pushing to change the TSH values in pregnancy, from what we consider the standard outside of pregnancy range, which I think we all know is a little off anyways, to being different for each trimester.
Dr. Weitz: Yeah. I think that you said you like to see it under 1.5, is that what you said?
Dr. Thompson: 2.5.
Dr. Weitz: 2.5.
Dr. Thompson: So I know Endocrine Society did recommend the change for the first trimester. So a TSH of 0.2 to 2.5 is considered the normal range. And I know then they said I think it was 0.3 to 3…. 0.3 to three for second and third trimester. I’m pretty sure that’s what they had, but this study is saying anything under 2.5 in the third trimester can be a risk sign for labor and delivery complications. This is just one aspect of what we know thyroid does in the process towards labor and delivery. There’s so many gaps in study on how a mother’s body goes into labor. Because up until now, nobody’s cared. Nobody’s done the research. Everybody’s cared about making a baby grow, or how do we get a baby out whenever there’s a complication in childbirth? But we haven’t really done the due diligence to put this together as well as we probably should so that we can prevent those complications from ever happening. Okay? All right.
Dr. Weitz: Crystal asked or she’s commenting too many healthy, low inflammation women go to 42 weeks. And so she stops omega-3s at 37 weeks and switches to primrose oil with-
Dr. Thompson: Don’t do primrose oil. Don’t do primrose oil.
Dr. Weitz: Okay.
Dr. Thompson: So yeah. So interestingly, couple studies on primroses oil, it was an old wives thing, right? So primrose oil has been used as a midwife thing for helping labor, right, and initiate labor and those sorts of things, because it’s got a little bit of prostaglandin type stuff to it, all these different things, but what we see in the studies… Or it helps to stimulate prostaglandins. But what we see in the studies is there’s different type of types of prostaglandins. And one of those groups is the PGI group, okay? That’s an anti-inflammatory group. It does some other things. It mitigates and kind of competes with thromboxane A2. And what we see with evening-primrose oil is it’s really good at increasing PGI prostaglandins, but not PGE2 and PGF2 alpha. And so what we see is that you take too much evening-primrose oil and you can’t clot. You can’t clot in labor. And so it increases the risk of complications in labor, it doesn’t help them. I have an article on my website about it that goes into more detail, because it is something that I was told to do in my pregnancy. My midwife was all about it, it was an old midwives’ thing and it was based off the fact that it is really good outside of pregnancy, right? We use it a lot for women’s health complications, but it’s not so great in pregnancy. Okay. So just sorry, a little tangent.
Okay. And I did see somebody talking about, let’s see, premature rupture of membranes and those sorts of things, right? So premature rupture of membranes can happen due to a number of reasons. Sometimes it is bacterial and vaginal infections. Like you see more PROM with GBS positive moms, yeast infections that went undiagnosed, that sort of stuff. The other thing you can see is, so the surfactants that are being produced by baby’s lungs are usually neutralized by antioxidants in the amniotic fluid, specifically vitamin C and vitamin E. And we’ll see in studies that deficiencies in vitamin C and vitamin E do increase the risk of premature rupture of membrane. So it can be a little bit of all that stuff. Usually it is an inflammation type thing, but usually due to something along those lines. Yeah.
Dr. Weitz: We know preeclampsia can be a problem and we were talking about blood sugar and insulin?
Dr. Thompson: Yeah. So what’s… I’m sorry. I missed the question.
Dr. Weitz: Oh, so what do we do if there starts to be issues with preeclampsia?
Dr. Thompson: Oh, so, and it depends on pattern of preeclampsia. So there is no one pattern of preeclampsia and oftentimes, it is acute crisis management at that point. And there are some tips and tricks to reducing the symptomology, just depending on what that presentation is. Sometimes we’re doing things like I’m sure everybody has heard of the Brewer’s diet, right? Where we’re pumping people full of milk and eggs. And the idea there is are we fixing the problem? No. Right? When somebody has preeclampsia and they’re spilling protein, we’re causing protein deficiencies throughout the maternal physiology.
And by making them eat a half dozen eggs a day and a half gallon of milk or whatever we can get in them, we are supplementing their protein knowing that they’re going to lose a bunch of it, so that we don’t feel the damage from that protein loss. So those are things that you do crisis management. I’ve seen some cool studies that talk about using., And I have in clinic very successfully, using superoxide dismutase and manganese supplements for things like HELLP syndrome.
And I’ve actually done that very successfully in clinic, [inaudible 01:16:09] cystine. Anytime I have a patient who is over a specific age or did a in vitro fertilization, I always put them on a coenzyme Q10 for pregnancy, because we see in the studies that it helps reduce the risk of preeclampsia in those cases. There is a researcher out of the Ecuador, last name, Teran, T-E-R-A-N, and they are doing a ton of research on CoQ10 in the prevention and treatment of preeclampsia. So there’s definitely some things you can do. It’s very much case by case.
Usually, we’re looking at things like magnesium. So one of the things that can be added to the first trimester supplement regimen, right? Of all the things, would be a magnesium. We do see that magnesium is needed for the proper vascular development of the placenta to the uterine there. And that magnesium deficiency in the first trimester can cause changes to that vacuolation and increase that risk of preeclampsia. So that’s something on the maternal side that can increase that risk, where most of that risk does come from the embryo itself.
Dr. Weitz: And is there a form of magnesium that you like?
Dr. Thompson: I tend to go with magnesium glycinate, glycinate, however you say it, tomato and tomato. I like the magnesium glycinate. I usually use a powdered form as well. I just find it works better for some reason versus doing the capsules. So again, there’s a couple different brands. Vinco has one, Seeking Health has one, Klaire has one. Those are all brands that have a powdered magnesium glycinate.
Dr. Weitz: [inaudible 01:17:51].
Dr. Thompson: Yeah, so this stuff, yay. Cholesterol… Oh, more magnesium. We never touched back on magnesium here. So the other thing you need kind of like how you needed magnesium down here for oxytocin to work, you also need magnesium up here for oxytocin to bind to the receptors for active labor to occur. The other big one here is that hyaluronic acid aspect. There was a really interesting study and I can’t remember what year it was, but what they did is they went through and they compared the different induction methods. And they said Pitocin, prostaglandins, if we do this treatment, what is our live birth outcomes? What is our vaginal birth outcomes? What’s a cesarean rate? How many side effects do we have in a 24-hour period? One of the things that they did in that study or they looked at was the use of hyaluronic acid in induction methods. And what they did is they injected hyaluronic acid into the cervix and they did it every three hours. And what they found was that there was a greater than 90% vaginal birth rate with that group with no side effects.
Dr. Weitz: That’s incredible.
Dr. Thompson: No side effects were found in that study, but it was deemed unusable because nobody liked getting injected in the cervix. That doesn’t sound fun. You got to put a speculum in, you got to get the needle in there. It’s not fun. Nobody wants to do that when they’re in labor.
Dr. Weitz: Not only that, but the hospital got paid a lot less too.
Dr. Thompson: Right? Really more than anything, what this study did was it kind of highlighted the importance of this last phase of all of this progression. Everything kind of culminates to this production of hyaluronic acid, right? You can have a cervix that everything’s parallel, the fibers are nice and squishy, maybe you’ve got a head… I’m kind of going the other way. Pretend there’s a head in my arms here pushing against the cervix. We’re going upside down today. But that cervix can’t open because there’s no fluid in between the fibers, right? It can’t do it. You could have a 80% squishiness, but there’s no dilation to that cervix because the body hasn’t produced hyaluronic acid yet. Okay? There’s a lot of things that go into making hyaluronic acid too. Just like everything else, we have [inaudible 01:20:15] for these things to happen. Hyaluronic acid is made from carbohydrates. It’s made from sugar. You have to have sugar. You have to have carbohydrates. Specifically, we like starches and sugars, okay? Fruit, potatoes, dates. This is where dates come in. Dates help increase hyaluronic acid production. Not only do they have starch, but they also have two minerals that are needed in this, manganese and that darn magnesium again. Okay? You have to have magnesium in order to make the hyaluronic acid. You have to have these things. If we are low in that sugar realm, you can’t make it. Dates are known to help ripen the cervix. We see it in studies. This is why, it makes hyaluronic acid. Hyaluronic acid is also found in things like skin and cartilage, right? Bone and skin on chicken, carcass broth, these are all great things that help increase hyaluronic acid production in the body, helps to fuel that production.
But it’s something we never talk about. In my opinion, yes, all of this is very important. We have to have all of this stuff happen to get to this point, but when you look at the actual active labor aspect, you have to have that hyaluronic acid for that cervix to open, right? You have to have contractions to push that baby down. You have to have the prostaglandins that make that cervical fibers nice and squishy, but you have to have the fluid in that cervix. The other thing that fluid does is it fills all the tissue in the vaginal cavity, so when that head pushes through, we stretch, we don’t tear. Sometimes you’ll see studies that link longer labors to more vaginal tearing and really fast labors, right? It can go either way, because we didn’t get enough of any of the stuff in the vaginal tissue at that point, there was no love there and so it just couldn’t stretch. But same thing the other way, if you have long labors, you may not have had very much hyaluronic acid to fill that cervix. And now you’ve kind of used it all up, right? It kind of all went there and your vaginal tissues can’t stretch as well.
Dr. Weitz: What are… Are there any… What is some of the most effective things a woman can do who’s waiting to go into labor to maybe hasten that?
Dr. Thompson: So there are things that you can do, and there are things you can’t do, right? The best thing somebody can do in those last weeks is make sure their body’s preparing as much as possible, right? I always tell people to carb load, honestly. Eat some sweet potatoes, eat bananas, eat root vegetables, eat whole grains, eat the carbs, okay? Don’t be afraid of them. But a lot of this is hinging on the development and the growth of that baby. And if that baby’s not mature, you could be four centimeters, 80% baby could be at a zero station, you’re not going to go into labor until that baby tells your brain it’s ready. So there’s stuff you can do, but then there’s also this element of time and patience, which sucks. And it’s always hard when I have patients who come in and being an acupuncturist as well, we have patients all the time who are like, “Can you just induce me with acupuncture?” I’m like, “Mm, well kind of, but not really.” We can play with your hormones, we can play with your system, but if your baby’s not ready, it’s not going to do anything. You might feel a little bit, we might progress you a little bit, but you’re not going to go into labor until that baby’s ready.
Dr. Weitz: Sometimes women drink raspberry tea, there’s all sorts of-
Dr. Thompson: Yes, there’s castor oil, there’s a blue and black cohosh that people will jump on board with sometimes. There’s the whole evening-primrose thing. There’s a lot of things people do. But when you get to that last four weeks of pregnancy, the work was done before. And that’s one of my big messages that I want a lot of practitioners to know is the sooner you can get on board with [inaudible 01:24:11] and women too, who are present. I say this all the time, the sooner we can get to people, the more we can actually successfully change their childbirth outcomes.
If we can start working with them at 24, 28 weeks and making sure that they’re doing and we’re monitoring, and we’re seeing what’s happening here, the better that outcome is going to be. And if their outcome is better and they have a great vaginal birth, then their child is going to be set up more so for their health in the future. And there’s so many things that happen in the maternal physiology that changes mom’s postpartum health, right? Her birth experience may set her up for having things like postpartum depression. And we want to make sure that we make this as functional as possible for her so she’s as healthy as possible for the future or herself. And it starts way back. And sometimes we get to people and it is honestly just too little too late.
There’s only so much we can do with our medicine. And we can’t make miracles happen. You know what I mean? We can’t make something happen that isn’t just… It just can’t happen because we’ve missed steps. And we just, again, we don’t have the time in pregnancy care. In pregnancy care, you are limited on the amount of time you have to work on somebody. I have given people hyaluronic acid supplements in those last couple weeks of pregnancy knowing that maybe they haven’t been doing what they should have been doing or things don’t seem like her cervix is doing what it’s supposed to be doing at this stage. I know there’s a lot of people who are anti-cervical checks prior to the onset of labor, or even during labor. I’m not, I don’t think dilation means anything. I don’t think that number means anything. I do think the squishy factor means a lot though, right? I think the effacement number, what’s the percentage of softness in that cervix does tell me something. That cervix should be squishy. There should be some softness to that cervix by 36, 37, 38 weeks. We should have an element of squishy there. If not, we got some work to do. We got to play catch up.
Dr. Weitz: It’s getting pretty late, but would it be okay one more question?
Dr. Thompson: Yeah.
Dr. Weitz: Crystal’s asking about things we could do to reduce the likelihood of postpartum depression, and she mentioned methyl Bs.
Dr. Thompson: Yeah. That’s one aspect. Another aspect is looking at anemia in the third trimester correctly. And thyroid, both of those, subclinical hypothyroid in the third trimester associated with more postpartum depression. Anemia in the third trimester is associated with more postpartum depression. And we know depression can be just a sign of weakness at a cellular level, the body being run down. So there’s a lot of elements that go into postpartum depression. And if we’re looking to prevent postpartum prevent… Oh my gosh, prevent postpartum depression. Wow, that was quite the tongue twister for me there for a second. Everything in pregnancy, we have to work backwards. So if somebody has postpartum depression, we have to go back to that childbirth experience. If we can make them have a nice happy, healthy childbirth experience, they’re going to be less likely to have postpartum depression. We go back further. If we can help prevent them from having anemia in the third trimester or making sure that their thyroid is functioning properly and doing things like that, then we can help prevent them from having things like postpartum depression later.
And methyl Bs, yeah, those can definitely play a role in that. Only 20% to 30%, depending on age bracket of anemia and pregnancy is associated with avert iron deficiency. I think we over supplement iron in pregnancy. Sometimes it’s associated with B vitamin deficiency. And so we can see that B vitamin deficiency issue, things like methyl Bs and MTHFR, all that kind of stuff being further back, creeping its head around, and it’s just so borderline, borderline, borderline, then we have a rough childbirth experience, or maybe we lost a little bit of blood and we were already anemic. And now we’ve set ourselves up for this depression pattern because now we have to recover from childbirth and neurotransmitters are not on the forefront of that recovery. So a lot of different things can go into that pattern. Yeah.
Dr. Weitz: Great. So this was a tour de force presentation. Awesome.
Dr. Thompson: Right. Thank you. Well, I appreciate you having me. This is my passion. This is my heart, so-
Dr. Weitz: It comes through, you are so passionate about this topi.c for those who’d like to get ahold of you, how can they get ahold of you and both for patients and also, do you consult with practitioners as well?
Dr. Thompson: So I am currently in the works on a couple of different things. Anybody can get ahold of me via my email. So it’s hello@sacred or not sacred, firstname.lastname@example.org. That’s the other email, that’s the clinic. This one will be more direct to me. I also do for patients, I always do free phone consultations before they ever schedule an appointment. So they can always jump on the website for the clinic, which is sacredvesselacupuncture.com and go to the scheduling option and just schedule themselves a free 15 minute phone consultation. And I’m more than happy to chat that way. As for upcoming things on mentorships, yes, we are working on putting together some mentorship programs. I’m looking to put together actually something similar to what you got here, which is more like a once a month case study review for practitioners, where everybody can send in a case study and we’ll go over them over a course of a couple hours and do that once a month. So you can keep an eye on the website. So that’s the functionalmaternity.com website for updates on that. And that should be coming up hopefully some time this summer. Any midwives in the South or Midwest region, I will be teaching at the Midwifery Wisdom Conference in Galveston, Texas in November, where we’re going to talk specifically thyroid and nothing but thyroid. Should be fun.
Dr. Weitz: And your book is available…
Dr. Thompson: Yeah, my book is available on Amazon, or you can order it through your favorite local bookstore. I’m all about supporting the local bookstores. It’s Functional Maternity: Using Functional Medicine and Nutrition to Improve Pregnancy and Childbirth Outcomes. And people can always just email me too, I am more than happy to talk to other practitioners and help where I can just via email without it ever having to be a big formal thing. I want practitioners to know and I want women to get support. So I feel like I’m always available to help where I can.
Dr. Weitz: Great. Thank you. Thank you so much.
Dr. Thompson: Yeah, of course. Thank you.
Dr. Weitz: Thank you for making it all the way through this episode of the Rational Wellness Podcast. And if you enjoyed this podcast, please go to Apple Podcast and give us a five star ratings and review. That way, more people will be able to find this Rational Wellness Podcast when they’re searching for health podcasts. And I wanted to let everybody know that I do now have a few openings for new nutritional consultations for patients at my Santa Monica Weitz Sports Chiropractic and Nutrition clinic. So if you’re interested, please call my office, (310) 395-3111, and sign up for one of the few remaining slots for a comprehensive nutritional consultation with Dr. Ben Weitz. Thank you and see you next week.
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