Introduction
Hi everyone. Dr. Eric Westman, here and welcome back to my channel, where I review and debunk nutritional misinformation online. From time to time, I get to interview the movers and shakers in the world that I think that you need to learn about. And today, Lily, please introduce yourself.
Introduction and Background of Lily Nichols
Lily Nichols: Hi! Well, thanks for having me. My name is Lily Nichols. I’m a registered dietitian and diabetes educator. I’ve long been an advocate for a real food diet, and I also speak pretty extensively on macronutrient composition of the diet. So a lot of people, probably in your sphere, who know of my work in the gestational diabetes space, or the pregnancy space. I have several books, Real Food for Pregnancy, Real Food for Gestational Diabetes, and Real Food for Fertility, the first of which was on gestational diabetes. And the whole reason that I felt that book needed to come into the world was that I had worked in the gestational diabetes space, both at the policy level, at the state of California, and also in clinical practice. I was the main diabetes educator at a very busy perinatology practice that focused on gestational diabetes. And I found that when you tried to apply the conventional advice to that condition, it often failed, mostly because the macronutrient composition is a mismatch for what the condition really is, which is insulin resistance in pregnancy. And it didn’t make sense to me that we were providing such a high-carb diet for these women who clearly had a carbohydrate intolerance issue. So it’s like, okay, here you take a glucose tolerance test and you fail it. Well, now let’s provide you with a meal plan that gives you that same amount of carbohydrate multiple times a day and expect your blood sugar to be good. You know, it didn’t make any sense.
Dr. Eric Westman: Well, well, that’s a lot to unpack. First of all in the gestational diabetes: so you just found out you’re pregnant. You go in, you get a glucose tolerance test, right? Not unlike what used to be done for adults, but most doctors don’t do that anymore. How much glucose is in that test these days?
Understanding Gestational Diabetes and Glucose Tolerance Tests
Lily Nichols: Depends on which version of testing you’re doing. It can be anywhere from 50 to 75 to 100 grams.
Dr. Eric Westman: So the adults, so most of my patients they may be thinking about their children or grandchildren. Most of my patients have reversed their medical issues as adults, and now maybe you have to be reminded about the special case of pregnancy but they wouldn’t, as an adult, want to drink 75 grams of glucose at once. In fact, you can check on your continuous glucose monitor and see that your blood sugar will rise like this. But of all the fields, I’m an internal medicine specialist. The ob-gyns have known for a long time in obstetrics that if a woman has trouble handling that glucose load, they get diagnosed with gestational diabetes, and then, as a routine, they’ve been told in the past to cut the carbs out, or at least to reduce them or go on insulin to handle the blood sugar during pregnancy. So it’s kind of obvious to most of the people who watch me or have been listening to me, that if you eat or drink sugar, then the blood sugar goes up. So, to minimize the amount of blood sugar going up, you minimize the carbs in the foods. But tell us a little more about this special case. What happens with the insulin resistance when someone’s pregnant?
Lily Nichols: Well, I mean, insulin resistance is going to happen in pregnancy. It’s part of the natural physiology of pregnancy. However, that doesn’t necessarily mean it’s the physiological norm for blood sugar to go up over the course of pregnancy, so your pancreas will produce more insulin as the pregnancy progresses to combat that insulin resistance. But actually, blood sugar tends to run a little bit lower in pregnancy. If all these adaptations have gone as expected, what’s happening now is we have such a high proportion of the population with underlying insulin resistance, they come into pregnancy they have no idea that they’re prediabetic or borderline prediabetic, so they’re already have kind of the cards stacked against them, and then occasionally you’ll have somebody who’s generally pretty metabolically healthy, but their pancreas really struggles to produce larger amounts of insulin as the pregnancy progresses, but that is a much smaller proportion of the type of gestational diabetes we’re seeing. There was a recent study that looked at different gestational diabetes subtypes, and the vast majority fell into the insulin resistant category. So they’re actually producing more insulin than necessary but they already had a baseline of insulin resistance. And the next category had what they called a mixed defect, where they had both insulin resistance and their pancreas is kind of struggling. And then, the last group, the very smallest proportion, they didn’t have baseline insulin resistance, but their pancreas struggled with the adaptation of pregnancy. So when you have that so-called “diagnosis” of gestational diabetes, all the diagnosis is high blood sugar during pregnancy but there’s many different ways that it can present itself.
Dr. Eric Westman: Yes, so the idea of insulin resistance being from high insulin levels themselves kind of holds true here. If someone comes in, they’re already having high insulin levels, which is, I think, the root cause of insulin resistance. Basically, your body is turning down its desire to listen to the insulin like you’re in a loud room, your ears naturally turn down the hearing so that it’s not so loud. So you could fix the insulin resistance of gestational diabetes by lowering the insulin level by a low-carb or low-cal kind of diet, or you could, like many adult diabetologists do, still do, I’m afraid, add more insulin to a place where there’s already plenty of insulin, which is not going with the pathophysiology. The insulin is already too high. And what have you found to be effective remedies for this, or maybe just kind of guidelines for all women who are going to be pregnant and then, I guess, get into “what does the baby need to grow”. That’s really what the mom wants to eat, right?
Lily Nichols: Right and I think you hit the nail on the head, conventionally, the way that it’s often treated is by to some degree, controlling the carbohydrate intake, but I’ll speak to where the guidelines are on that, because that’s the reason that I had to write all the things that I’ve written, and why my work is so controversial. But a lot of times they’re given really more of a consistent carbohydrate diet. So we’re avoiding unexpected spikes, but we have a more predictable pattern of spikes, so to speak.
Dr. Eric Westman: That must be better. Oh, sorry.
Lily Nichols: Right. And so if your blood sugar is higher than expected, there’s only so low, conventionally, they want you to go with carbohydrates. So the guidelines are no less than 175 grams of carbohydrates per day. That’s the magic number for pregnancy. Yes. So the whole controversy with the whole pregnancy world, and why so many people don’t want to touch pregnancy guidelines with a 10-foot pole is like, we don’t want to do anything that would harm the baby.
Dr. Eric Westman: Although diabetes doesn’t harm the baby. Wait a minute…
Lily Nichols: So I’ll get into it. But so conventionally, they keep carbs at no less than 175 grams a day, split through three meals and three snacks, and then if the blood sugar remains high, you treat with either insulin, sometimes metformin, sometimes glyburide, but it’s like, you just medicate. And so what I was seeing that was, when you applied the conventional guidelines, that they failed miserably, because you’re working with somebody already with insulin resistance, and then we’re providing them at least 45 grams of carbs at each meal, sometimes more, if they’re somebody who has higher caloric needs, and it didn’t work, obviously. It doesn’t take more than like a toddler level logic to see that the gaps are there. The challenge, though, was proving that going lower carb is safe because there are concerns that if you put a woman on a low carb diet, then she will have higher ketone levels. And the old school thinking is that ketones harm neurodevelopment. Now, that was all based on flawed research, and really a lack of research, and most of the extrapolations about ketones being harmful to fetal brain development stemmed from data on either starvation ketosis or full-blown diabetic ketoacidosis. You and I and probably most of your listeners know that there’s a difference between those and nutritional ketosis. So it took a lot of unpacking of the literature for people to trust me when I was like, no, actually, we should titrate the carbohydrates down to a person’s carb tolerance so they’re not getting glucose spikes, and simply increase their calories to meet their needs through other lower carbohydrate foods. So you just increase the protein and the fat, and the non-starchy vegetables, we can still meet all the nutritional requirements, still get them a calorically adequate protein, adequate diet and simply achieve glycemic balance, and all things are good, but that took a lot of work for people to understand that that would actually be safe.
Dr. Eric Westman: Yes, well, even, let’s get to the reality in a moment. But the guideline or what the science really says in physiology, but the guidelines still are stuck at high carb and avoid ketosis, right?
Lily Nichols: Yes.
Dr. Eric Westman: And avoiding ketosis is really sort of a false barrier, false guardrail. I mean, it took me 20 years of teaching and learning to realize that everyone goes into ketosis if you don’t eat for two days—everyone.
Lily Nichols: Even overnight for most people.
Dr. Eric Westman: Well, I was thinking of the diabetic, but if you’re metabolically flexible, it’ll be overnight. So how could something be harmful or, or even just if everyone does it when there’s no food, right? So even the most staunch anti-keto people will be happy that they go into ketosis when they don’t or can’t get food for a few days. And it actually happened to me when I was looking at my cellphone that now has changed. I remember using phones with cords, and in fact, my office still has one of those old things, and they still work. But the phone was out of battery, and it said and I was kind of looking at it, do you want me to go into self-destruct mode? It said to me, I kind of hallucinated it. I must been sleep deprived. No, it’s not what it said. It said, do you want me to go into safe mode? So if you’re developing a machine, a human, an animal, and there’s no energy around, you go into safe mode. You don’t go into self-destruct mode. And yet, then I would go on the internet and watch doctors cluck away about how harmful ketosis was and how mothers, pregnant women, must be eating carbs because ketosis is bad, and yet we do it. We all do it when we don’t have food around, and that’s because we store energy as fat. It actually makes sense. And so I think there’s a false barrier to be worried about having ketones in the blood, although the name probably has to be changed. There’s a group now Isabella Cooper in the UK, where they coined the term “euketonemia,” which means a normal amount of ketones in the blood—normal ketones in the blood, not ketosis.
Lily Nichols: I like that.
Dr. Eric Westman: We’re all taught “ketosis”, like halitosis, it means the abnormal condition. So it’s the first time I’ve seen it in the medical literature, they say, euketonemia. I mean, Dr. Atkins wrote “benign nutritional ketosis” years ago in his books; we just kind of kept the nutritional ketosis term. Steve Phinney will talk about nutritional ketosis, but I think it’s important to change that to at least ketonemia, is what I was thinking. You don’t have to add the eu to the front of it. That’s a little maybe too scientific, but I don’t think we should be worried about having pregnant women be in ketonemia. What are your thoughts about that?
Lily Nichols: Yes, well, the interesting part, and it’s been really interesting for me to watch. We have more data on ketosis in pregnancy than we did. I wrote Real Food for Gestational Diabetes in 2015, so that’s over 10 years ago. There’s a lot more data that’s been published on it. At the time, there was no data published on what is normal maternal ketonemia in pregnancy, so we were going mostly off of studies based on urine ketones, which have really very little to no correlation—at least in pregnancy—with blood ketone levels. And so we’re kind of guessing at what’s normal. So we did have data going back to at least the 1970s. We knew that pregnant women were at least three-fold more likely to go into ketosis overnight, after an overnight fast, compared to non-pregnant women. You just very readily go into ketosis. And it makes sense. We need to dip into that, that backup energy system, when we don’t have food coming in, because you have a baby growing that’s taking from you, 24/7. So it makes sense that we’re going to be more metabolically flexible, I guess, in a way, in pregnancy, and tap into whatever fuels are necessary.
Dr. Eric Westman: Well, I learned this through going to a meeting in Jakarta, Indonesia. This was pre-pandemic. A father basically organized the meeting because he had been for years teaching doctors in Indonesia about low-carb and ketosis and how it’s okay. And the reason was, his son was born with cerebral palsy, and when he went to the doctors—he’s an engineer, so most engineers are kind of pains as patients, because they always ask questions, you know, why? Why? Why? And, I mean, I love it if I have time. But so Tio (the father) had a son with cerebral palsy, and asked, well, what can we do? What’s going on? And the doctors said, well, there’s not enough myelin in the brain. And he said, well, how do we get myelin in the brain? Well, you have to have cholesterol to make the myelin. Well, how do you get cholesterol? And he just kept asking, and it turns out, children use ketones to get the cholesterol made in the brain. And so he learned about ketones, and not as a bad ketosis, but as a fuel and actually a substrate for brain development for children. And it just kind of took that like a bulldog. And so I learned about women not eating carbs during pregnancy from the Indonesian doctors who said, oh yes, well, we’re a Muslim country, mainly, and most of the women fast during the day, and especially during Ramadan. So it was a comfortable fit. They’re not scared of not eating during the day. I mean, that just kind of defies how in my typical clinical practice, people can’t imagine not eating during the day. We’re just conditioned to have food all around. And if it’s carbs, it’s turning off ketones. So basically, you need ketones to help brain development, and that’s probably why a pregnant woman is so flexible to get the ketones to the growing fetus and there’s the growing baby. There’s a saying, and I think it’s pretty much true, that babies are born in ketosis, except the first moment they get carbohydrate, if it’s a breastfeeding mother who’s eating carbs, even they may be knocked out of ketosis and they might even be given a seizure disorder. For those who have learned about the ketogenic diet for epilepsy, often it’s not until they’re ten years old where a doctor says, or the parents wake up and say, well, hey, why don’t we try a keto diet for my child with epilepsy, and there are like, in one out of 20 of these kids, the seizures go away overnight. The flexibility of having ketones around gets stopped when you add carbs into the daily diet. So what are your thoughts about that?
The Role of Ketones in Pregnancy and Lactation
Lily Nichols: Well, I mean, long ago, and it’s actually still a lot of people believe this, they will teach that the fetal brain needs glucose to grow properly, and there’s this idea that ketones are going to harm them, but it’s now shown, 30% of fetal brain energy needs are actually met by ketones. And of course, our bodies also have the ability to create glucose. So this idea that we need to be eating all this extra glucose to meet fetal brain energy needs is a false assumption. The baby is going to grow from all different fuels, not just glucose and ketones, but lactate and amino acids and such. There’s all sorts of different fuels that are used, but really, it’s the physiological norm as pregnancy progresses for ketogenesis in the mom to increase so you more readily go into ketosis in late pregnancy, because the metabolism shifts from an anabolic state to a catabolic state in the latter portion of pregnancy, where you are not only sending like glucose and other fuels, but you are also tapping in, literally, to your fat reserves to fuel that baby’s growth, and that also continues into lactation by the way. A lot of the weight that you lose during lactation is from the breakdown of maternal fat stores that you accrued over the course of the pregnancy, and so babies really should have exposure to a state of ketosis in utero, because you’re right, when they are born, they are born in a state of ketosis. They’re in the deepest state of ketosis in the first few days of life, before the colostrum shifts over into mature breast milk. But breastfed babies do actually stay in ketosis even for the full first month of life. Even in mothers who are consuming lots of carbohydrates, the babies still remain in ketosis.
Dr. Eric Westman: How do you know that?
Lily Nichols: There’s data on it. There’s data published on ketone levels in babies. If they’re switched to formula which is much higher in sugar, then they are not in ketosis for quite as long. But breastfed mothers, yes. Actually, a significant portion of the carbs in maternal breast milk is human milk oligosaccharide. So it’s fibers, essentially that feed the gut microbiota of the baby. Not all of it is maternal lactose, but even in women who are in ketosis, they of course, won’t have the same levels of fructose or something that a woman consuming a lot of sugar will have in her milk, but you produce lactose in the mammary gland tissue itself, so there will still be lactose in breast milk, even in a mom who’s in full-blown ketosis.
Dr. Eric Westman: Well, are you aware? So I did a rudimentary search looking for ketones in neonates, and the levels weren’t so high that it was remarkable to me, but there may be variability. I didn’t actually look at the specific articles themselves, but in talking to a few women at meetings. So for years, I go to 2, 3, 4 meetings on keto diets a year, and there are a couple, one who comes to mind, who sent her breast milk to UCLA or some other university in LA. And they, for a fee, will measure the content of the breast milk. And so she did that once. I said, well, do it again. The old kind of, well, do it again. Let me just see if it’s replicable. And when she does keto, the amount of her breast milk goes down, but the caloric content goes up because it shifts to fat and I was introduced to this because one medical resident years ago, who was pumping for breast milk, could just demonstrably see there was more fat as she froze the pumped breast milk in the milk. But even if a woman is not breastfeeding, if a woman’s breastfeeding but eating tons of carbs, they’re able to have ketones, no. But when they’re pregnant that’s a powerful push toward ketosis. If the pregnant mother is eating carbs and yet still pushing it.
Lily Nichols: Will probably go into ketosis overnight. Even if she’s eating a high-carb diet, she’ll probably go into ketosis overnight. And I know this because when you have women with gestational diabetes in some clinics, they’re still testing obsessively urine ketones, and they want them to test urine ketones every morning. And so they’ll be spilling ketones in the morning, no matter what they do, no matter how much they carb load the night before. Of course, that’s screwing up their fasting blood sugar. But nonetheless, you’re still spilling ketones. And I can tell you for myself, my own two pregnancies, I don’t necessarily eat keto. I eat what I call moderately low-carb, and I have the metabolic flexibility to do so. I err on the lower carb side, but not keto. And every single time they would test my urine ketones, present every single time. Even if I had a piece of fruit right before the visit, I would still… like my body was just so readily in ketosis.
Dr. Eric Westman: Sometimes I think of things in the big picture view, like, why would this happen? Teleologically, it’s because the baby wants them. The baby’s gonna send out signals to draw upon your fat and to grow, unless you’re under the really extreme condition of hyperemesis gravidarum. So if a woman gets terrible nausea and can’t eat for a week or two, somehow the baby, in most cases, still survives, right? That must be a keto process.
Challenges and Controversies in Treating Gestational Diabetes
Lily Nichols: Yes, for sure. And you’re right. I mean, there has to be also some sort of, like biological reasoning for it, over like the course of human history and evolution. You go back. Beyond the agricultural years, we had so much more food scarcity when we were reliant upon what was hunted or gathered. You wouldn’t want a pregnancy to suddenly be non-viable because we didn’t have food available for a couple of days. So of course, we’re going to have these mechanisms, but you’ll find this really interesting. There was a study published in 2024 and they looked at carb intake in pregnant women versus blood ketone levels, and they actually found no correlation between carb intake and ketone levels. I’ll send you the link to the paper. It was fascinating. It wasn’t a huge study. It was just over 100 women, but it was at 28 weeks of pregnancy, and they had a range of carb intake from maybe about 75 grams, all the way up to upwards of almost 400 grams (per day), and there was no reliable correlation. So blood ketone levels were simply maintained within a fairly limited range across a spectrum of dietary habits.
Dr. Eric Westman: Do you remember what the numbers were offhand?
Lily Nichols: Let me see if I can see. I’m looking. Range was 0.02 to 0.3 mmol/l.
Dr. Eric Westman: Well, so that’s kind of low compared to the level of keto. That’s blood beta-hydroxybutyrate levels.
Lily Nichols: Correct.
Dr. Eric Westman: Yes. So the range of what normal ketosis is kind of keeps widening over time, as more people are being studied. At first it was this kind of narrow range, and now, if someone is measuring blood beta-hydroxybutyrate, it might even be 0.3 or 0.5 (mmol/l) being called ketosis. I don’t even ask people to measure ketones, because most people have ketones, but some don’t and that makes them frustrated that things aren’t working because they think they’re not in ketosis. No, the goal is for it to work, not to have measurable ketones. That’s one of the things on the internet ketone, or internet keto today, gets people a little bit astray, but thank you for that reference. I would like to see that, but it would make sense that if the baby needs ketones, wants ketones, then there’s going to be a mechanism for that to be there, even if the mom’s eating carbs.
Lily Nichols: Well, the placenta actually creates ketones itself, too. So when there was a study out of Japan, I think the first, there’s been a couple of papers that have come out of this group, but the first one, I think, was 2016, and they looked at ketone levels in maternal blood at delivery, cord blood. So fetal blood supply, the placenta, and the placenta, by far, had the highest ketone levels of all, suggesting that it’s actually manufacturing ketones itself.
Dr. Eric Westman: Well, that would kind of make sense. But then we know, when you mentioned brain energy, there’s a difference between brain growth and providing the brain energy. This is a common separation of an adult with heart disease. For example, there are many different aspects to the heart. And so here the brain needs the ketones to develop, to make cholesterol, while it could be using glucose, it’s the energy supply. The idea of the placenta being a ketone generatot. I think there was a glimpse where there were some studies going on at Duke looking at ketogenesis. It was in regard to these SGLT2 inhibitors that make the urine leak glucose. And I was talking to one of the fellows doing animal research, and he was basically saying that there are a lot of tissues that can make ketones that we just don’t talk about. The idea that the kidneys make ketones was kind of an old idea, well, no glucose comes from the kidneys. It’s not common knowledge that kidneys make ketones. And so anyway, we’re just kind of learning about the whole body’s generation and use of ketones, which is exciting. But also to see placenta. That’s really neat.
So, now more to more practical things. Are you teaching? Do you coach? You have the books and all, but I’m learning now from folks who are influencers. I like the practical, hands-on, day-to-day knowledge that we’ve generated at Duke for years, and other people have, too. What are you up to these days? What can you teach me?
Lily Nichols: Yes, well, I teach in a couple of different avenues. I mostly focus actually, on mentoring professionals these days. So I have the Institute for Prenatal Nutrition, and I run a professional mentorship program for health practitioners there. I run that once a year. I do have an online course for gestational diabetes where I teach the full protocol with a bunch of extra resources to help individuals going through gestational diabetes at the moment, and that includes a lot on ketosis. I also have a handout in there for them to share with their provider if they happen to have a provider who’s really freaked out about the urine ketones, to kind of assuage their fears, because that can be a big barrier. A lot of times, they’ll see ketones and then suggest that the client is not eating enough or not eating enough carbs, and you need to eat more carbs and go on the insulin if it’s not safe for your baby’s brain to do anything else. So I have lots of resources in there for helping with that interchange because so much comes down to what the providers are educated on. Yes, those would be like the main avenues. I do have individual webinars, including one on gestational diabetes for practitioners from the Women’s Health and Nutrition Academy. So I do have one-off webinars for more bite-sized content, versus a full on mentorship if people are interested. And I write lots of articles on my website, Lily Nichols RDN, for people who want to just read. There’s no paywall. It’s not a Substack. Been writing there for well over a decade now. So there’s lots of resources up there, too.
Dr. Eric Westman: Great. And you spoke at the Metabolic Health Summit, which is one of the most scientific meetings for low-carb, keto and metabolic science. That’s awesome.
Lily Nichols: Funny. I spoke there more on fertility, on how metabolic health starts in utero. And then I got so many questions in the follow-up about low-carb and pregnancy. I was like, I need to come back and teach on that, because I taught on that topic at Low Carb Denver a few years prior to that, and I think that’s a topic that we still need more education on. So many people are comfortable with low-carb outside of pregnancy, but when it comes to pregnancy, it gets that much more controversial. And nobody wants to do something that could potentially harm the mom or baby. I get it, and I think there’s a way to pull it off, and you can do it in a way that actually nourishes mom and baby even better than the alternative. This is an interesting stat for your listeners: the number one predictor of inadequate micronutrient intake—so, low vitamin and mineral intake—in pregnancy is poor carbohydrate quality. And we’re in a state where the average American gets 58% of their calories from ultra-processed foods. So mostly, like, those are refined sugar, refined carb kind of foods. And I think we can really push the needle, zooming out from the forest, or zooming out from the individual trees, I should say. That’s really a needle mover. If we just get people eating more whole, real foods, more protein-forward, not taking the fat out of everything, just having more fresh, whole foods, we’re going to reduce so much of the chronic disease burden and pregnancy complications. So yes, I’ll get off my soapbox.
Dr. Eric Westman: No, that’s great. And our first study , it was a study on PCOS. We use the low-carb method. It was a keto level of carb restriction, and it worked really well for PCOS. So even at Duke these days, sometimes I’ll get someone who has gone through all the IVF, they’ve spent a lot of money. It’s not paid for, typically. And then the doctor at the end will say, maybe you should just lose some weight. And then they end up in my clinic, and I get a card from a couple every Christmas, thank you, Dr. Westman, and then the baby is growing because often, it just takes a month or two of no carbs for the infertility to go away if it was related to PCOS.
Lily Nichols: It’s rather remarkable with PCOS. It’s highly responsive to a higher protein, lower carb diet.
Dr. Eric Westman: Well, the infertility area, the reason why a doctor wouldn’t—an IVF specialist—wouldn’t immediately think of nutrition is they’re mainly surgeons. Or they’re not nutritionally minded. I’m often trying to think of, why are some doctors so resistant? And the pregnancy issue is, like most of these things, it’s not just scientific; it’s social. It’s what typically is done, and it’s perception of doing something wrong, and it kind of heightens all those things such that if, even if it’s healthy for a mom to be in ketosis, but it’s not generally accepted, if something bad happens to the child, the parents sue or get upset, and then the lawyers can find plenty of doctors to say that ketosis was bad for you, and then they win the court case, even though the diet had nothing to do with it. It was years ago when they said: the top ten things the Atkins diet causes, and that one of them was sucking chest wounds. And car accidents. So everything will be blamed upon the diet, even if the science isn’t there. Within the court and within the practice patterns of doctors, if it’s really far afield, you still may lose, even though it’s the right thing to do. So that makes it more difficult in this space, don’t you think?
Lily Nichols: Absolutely, I think most clinicians don’t want to go against the guidelines. And I mean, I was right there in their shoes. I was being a good little dietitian and following the guidelines. So here’s your 175 gram carb meal plan, and I’m thinking I don’t think this is actually going to work.
Dr. Eric Westman: Well, that’s one shifting. That’s one reason why the SMHP—Society of Metabolic Health Practitioners—has come up with new guidelines that can support a wider range of carbs during a clinical practice. I don’t think ob-gyn is on the radar yet of the SMHP. That would be note to self for another practice guideline, but the idea that doctors are afraid of ketones is really just not knowing about it, I think, although I don’t know if there would be enough science now to write a review paper of how it’s normal and safe to be in ketosis during pregnancy. I don’t think there’s enough data yet. Or is there?
Lily Nichols: Yes, I don’t know that there’s enough data to necessarily push a ketogenic style eating plan. So 20, 30 grams carb total, no more than that, per day, I don’t know that the data is there for that specifically. But there was a review article in, I believe it was Diabetes Care, in 2021, I can send you the link afterwards. And they looked at whether our dietary recommendations for gestational diabetes, which a lot of which are really there to be ketone-avoidant—like the whole 175 gram of carb minimum—is to try to avoid ketosis. And they found that there was not enough evidence to support a higher carbohydrate intake just purely for the avoidance of ketones. It just it wasn’t there. So, yes.
Dr. Eric Westman: That reminds me of the irony: so, the city of New York was trying to get rid of Big Gulp sodas ao that you lower the sugar intake. And companies would say, well, okay, prove that taking away Big Gulps will lower the obesity rate. And it’s like, no; they should have had to have proved that putting soda in Big Gulps didn’t raise the obesity. So no, the “powers that be” really should have to prove that you have to have carbohydrates during the pregnancy. Of course, that’s when you’re in the power position and the perception of everything else is bad and wrong. And the heightened worry about medical legal issues in pregnancy is, I think it’s fascinating. And I mean, I broke my first guideline by mistake, and this is often the way you can talk about it. A friend of mine was treating someone, a doctor friend, with an A1c of 12. So the blood sugars were so out of control. The A1c was 12% and he worked upstairs, down the hall in the same area, and he said, here, take this list, is the low-carb keto list, and go see Dr. Westman down the hall. I don’t know, well, it took three months for him to get to me so all of the guidelines would say this man needs to be on insulin, you look out of control. Oh, my god, he’s at risk and all that. By mistake, he went home, followed the keto diet, and his A1c was 5.5 when he came to me and we didn’t use insulin. But we violated the guideline.
Lily Nichols: Well, he had so much insulin circulating in his body already.
Dr. Eric Westman: I know. Well, you know that. Have you read Gary Taubes’s Rethinking Diabetes book?
Lily Nichols: I haven’t read that one yet. No.
Dr. Eric Westman: Well, it’s a hard read. It’s very dense—typical Gary Taubes, but in there, it basically tells the story that the insulin levels were high in type 2. It’s just that nobody measured it. The measurement of insulin in the blood was only available in the 1960s and by that time, the doctors were using insulin for those who were overweight or not type 1s. And so in that article—I unearthed it and went back to it—they measured insulin levels in these people with diabetes, but their weight was higher and the insulin levels were high. And they said in that article, it makes no sense to give more insulin to someone whose insulin level is already high. That would be like giving more thyroid to someone whose thyroid level is already high. But the field of endocrinology was already so in the practice pattern of giving insulin for these folks to lower blood sugar. Well, I’d say still, most diabetologists will mindlessly—and guidelines—will mindlessly just give insulin to a type 2 now, but the pharma world is developing these medicines that lower blood sugar without insulin. The GLP-1s and GLP1-s and GIPs, and there’ll be more shots down the road, but if you could use a medicine to lower the blood sugar and lose weight—not insulin—I mean, there are a couple papers where there’s criticism of using insulin for type 2s, and they’re by those companies that are making the other drugs.
Lily Nichols: Of course. Yes. When you look at those older research papers, like the 1930s, 40s, 50s, you get so much more actual data points and free thinking in those older papers, and in so much modern literature, they’re out there trying to wrap their mind around the cognitive dissonance needed to defend whatever is the standard of practice. They’re trying to, like, wrap their mind around this unexplainable thing, which is totally explainable if you just look at physiology, but it has to fit within their framework. And it makes it a bit difficult, as somebody who reads a lot of research papers, because you can get an argument so easily with either lay readers or people who are so entrenched in the ideology. “Well, in the discussion, they say…” And I’m like, yes, but it’s incorrect. This is an incorrect assessment. This is just a biased opinion piece at this point. Speak to the data.
Dr. Eric Westman: They call it a paradox. But really, it’s a paradigm shift that needs to happen. Well, getting back to the ob=gyn world and carb consumption, there was a physician who published papers for years, Lois Jovanovich.
Dr. Eric Westman: Yes, we worked together at the California diabetes and pregnancy program.
Dr. Eric Westman: But never went to the keto level. There’s still that fear of ketonemia, not ketosis. Ketonemia or ketonuria, although if you’re a carb eater, it is the abnormal condition of having ketones. So if you’re a carb eater, it’s ketosis. If you’re not eating carbs, it’s ketonemia. But the other there was a glimmer. There was a group in Texas that contacted us to create a study of lower carb diets among pregnant women, and in fact, they were so worried about it, the perception of it being bad, they wanted to do a post-partum weight loss study first to get familiar with the methods. And I thought that was kind of a brilliant way to ease it in, because the PIs (principal investigators) weren’t ready yet to have ketones in the patient. But now let me just get back to the levels of carbs. If you are otherwise able to tolerate carbs and you’re metabolically flexible, in my latest book, there are three different carb levels, and I don’t think everyone needs to be in ketosis. It’s definitely a therapeutic tool. And I’ve often said, well, I don’t really know if we really should be in ketosis forever. They’re early, but I’m waiting for science. Well, the younger researchers now are looking at what would happen if we were in ketosis before we have any medical issues? And so there’s a very provocative paper where 10 women in their 30s chose to do keto, and they’re doing it for, I think, an average of five years or so. And they looked at the blood, and it looked great, the markers of insulin resistance, even cancer, markers that we’re able to measure. Then they followed the UK diet of 280 grams of carbs today. And as you can imagine, everything went worse, and then they went back on a keto diet, and it looked better, kind of like before, so there was no permanent damage. It’s starting to raise the question in researchers’ minds, these young researchers, many of them don’t eat carbs. Actually many of them don’t even eat vegetables, which gets into that sort of carnivore space. What if some people are just so sensitive to vegetables and they do better without the vegetables at all? And I came back from a couple meetings in Europe this last summer, it raised that idea that maybe we should be in ketosis as a healthier way to be that old. Maybe it is the safe mode if you’re not having to run away from the wooly mammoth and you really just want to live as long as you can, tranquilly. I don’t know. But in your perspective, your signals that you’ve seen. Is there any harm from being in ketosis?
Conclusion and Final Thoughts
Lily Nichols: I don’t know that I could say there’s any harm. I think I really like to draw on the ancestral and anthropological information we have. There was a review paper, I think it was 2011, where they looked at modern, living, hunter gatherer populations and like, what is their like intake of carbohydrates, and it ranged from as low as 3% of calories from carbs, so ketosis and ketotic levels all the way up to maybe about 34% of calories from carbs, which, no matter how you slice it, that’s still less than where the guidelines are. The guidelines say 45 to 65%, and what was interesting is they looked at the latitude at which these people lived. And as you get closer to the equator, a larger portion of the diet comes from carbohydrates, which makes sense, because in the tropics, you have fruit growing year round. The forests are green year round. There’s plants year round. You go all the way up to the north of Alaska, and you’ve got two hours of daylight, maybe for the whole day. It depends how far north you go. But I’ve actually lived in Alaska before, and yes, in the winter, you can understand why these indigenous groups would not be eating virtually any carbohydrates. Any carbs that you may be eating would be what you harvested and then saved for the winter months. So I remember reading—I’m interested in foraging—I was reading a foraging book about how they would preserve the wild growing lingonberries, which they call “low bush cranberries” up there, which, by the way, are extremely tart. Delicious, but extremely tart. And they would harvest them and then preserve them in seal oil. So even whatever carbs you’re getting, they’re not sweet, and they’re preserved in fat. So you can see how their macronutrient ratios would be entirely different from somebody living in the tropics with an abundance of fruit. So I like to recommend a range of real food for gestational diabetes. I actually have three different meal plans at different levels of carbs, mostly showing how easy it is to adjust up and down from the different levels of carbs. It’s very easy to overeat carbohydrates, and I’d say most people underestimate how much carbohydrate they actually consume. But the point in providing different levels was that, I think for somebody especially who’s monitoring their blood sugar, we should be aiming for euglycemia (normal blood sugar levels). You should be aiming to avoid a problematic glucose spike, of course. And some people really are extremely carb-sensitive. Maybe the people who can’t tolerate any vegetables, there may be some separate things going on, and maybe genetically, they do well on a more carnivore-style diet, but from a blood sugar perspective, I see a wide range in carb tolerance. You have some people really eating a ketogenic diet, and they’re still struggling with glucose levels. And then meanwhile, you have a young, athletic girl, maybe she failed her glucose tolerance test because she doesn’t eat a super high-carb diet. So that amount of sugar was a bit of a shock to what her pancreas is used to releasing in terms of a bolus of insulin. But she actually does well with maybe upwards of 35, 40% of her calories coming from carbs, because she’s burning so much energy. So I really think it depends, but on average, I typically recommend maybe no more than a quarter of your calories coming from carbohydrates, with a pretty sizable portion coming from protein. I think the data on protein intake is really compelling on how we need a lot more than what the Dietary Guidelines recommend. And I don’t like when people take the fat out of all of their protein-containing foods, because when you do, you’re taking out a lot of the micronutrients that you also need from them, your fat-soluble vitamins and your CoQ10 and whatnot.
Dr. Eric Westman: Flavor for sustainability.
Lily Nichols: And flavor. But it does shock people. The clinicians who do my mentorship program, we have an assignment on a meal plan and also doing a full macronutrient and micronutrient breakdown, which many people haven’t done, either ever, or if you’re a dietitian, you haven’t done it maybe since school, and part of the reason I have them do it is that it’s surprising how quickly the fat adds up. So people hear a diet that is 50% of calories from fat or 60% of calories from fat, and they go, oh my gosh, that’s an insane quantity of fat, and then you look at it in terms of real food, and you realize it simply means you didn’t take the yolks out of your eggs. You cooked them in a tablespoon of butter. You had some nuts. You had salmon. You dressed your salad with some oil. You had some cheese and some avocado. It’s not like you’re just mainlining sticks of butter, but that’s the perception people have when it comes to the macronutrient ratios.
Dr. Eric Westman: Well, I think there are a lot of ways to be healthy in terms of the diet, but keeping the carbs in that range seems healthiest. The direct comparison was almost achieved in a study, a secondary analysis that Lucia Aronica did from the Stanford study called Dietfits. And if you did ultra-low-fat or ultra-low-carb, but you weren’t following them prospectively. It was a secondary analysis. There wasn’t their primary hypothesis to compare these two things; that’s a more accurate way to say it. The metabolic effects look very similar if you’re avoiding all the crap the junk food, ultra-processed stuff.
Lily Nichols: None of those are PC anymore.
Dr. Eric Westman: I’m a critic of the phrase “ultra-processed”. No, it’s okay to have processed meats, I think. But anyway.
Lily Nichols: Right. Because a protein powder could be ultra-processed by some of their definitions. Yes, I know. I hear you.
Dr. Eric Westman: So the McDonald’s apple pie is bad, but your mom’s apple pie is fine. In carb content, they’re equivalent or similar, but the metabolic effects of these two extremes looked really similar, so that I think there are lots of ways to be healthy. And thank you for sharing your insights today. I really appreciate that I learned a lot.
Lily Nichols: Thanks for having me.
Dr. Eric Westman: How do people find you or to find the latest that you’re doing? I think you mentioned it once, but just again, please.
Lily Nichols: So my main hub is my website. There are links there for my books, for my blog, for the services and offerings that I have, there’s even freebies up there. You can download a free chapter from my books, and then over on social media. I mean, I’m on all the platforms, although it seems to shift which platform I want to spend time on as time goes on, I’m mostly on Instagram these days. So Lily Nichols RDN is my handle there. You can find me on x as well.
Watch the full video here.
Speaker Bios
Eric Westman, MD, MHS, is an Associate Professor of Medicine at Duke University, the Medical Director of Adapt Your Life Academy and the founder of the Duke Keto Medicine Clinic in Durham, North Carolina. He is board-certified in Internal Medicine and Obesity Medicine and has a master’s degree in clinical research. As a past President of the Obesity Medicine Association and a Fellow of the Obesity Society, Dr. Westman was named “Bariatrician of the Year” for his work in advancing the field of obesity medicine. He is a best-selling author of several books relating to ketogenic diets as well as co-author on over 100 peer-reviewed publications related to ketogenic diets, type 2 diabetes, obesity, smoking cessation, and more. He is an internationally recognized expert on the therapeutic use of dietary carbohydrate restriction and has helped thousands of people in his clinic and far beyond, by way of his famous “Page 4” food list.
Lily Nichols is a Registered Dietitian/Nutritionist, Certified Diabetes Educator, researcher, and author with a passion for evidence-based nutrition. Her work is known for being research-focused, thorough, and sensible. She is the founder of the Institute for Prenatal Nutrition, co-founder of the Women’s Health Nutrition Academy, and the author of three books: Real Food for Fertility (co-authored with Lisa Hendrickson-Jack), Real Food for Pregnancy, and Real Food for Gestational Diabetes. Lily’s bestselling books have helped hundreds of thousands of mamas (and babies!), are used in university-level maternal nutrition and midwifery courses, and have even influenced prenatal nutrition policy internationally. She writes at https://lilynicholsrdn.com. When she steps away from writing, you can find her spending time with her husband and two children — most likely outside or in the kitchen.
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