Monday, March 21, 2011

Reality Check: The Brewer Diet is Not Evidence-Based

Many Childbirth Education methods teach that following the Brewer Pregnancy Diet will reduce the expectant mother's risk of complications, including pre-eclampsia. I have promoted the Brewer Diet myself in the past. The truth is that the Brewer Diet does not have any good research out there backing it up. Dr. Brewer's statistics from his patients are very un-scientific. It is hypocritical for people to accuse obstetricians of not following evidence by requiring intravenous fluid and continuous fetal monitoring (procedures not proven to be beneficial), and at the same time encourage pregnant women to follow a specific nutritional plan that has no randomized controlled trials backing it up. "But isn't good nutrition always a good thing?" you ask. Well, yes, but there are some specific problems with the Brewer Diet itself (many of these I learned from reading a comment response by Navelgazing Midwife on her blog post, Hypocrite in the Middle).

Drawbacks of the Brewer Diet:
  • The Brewer Diet can create stress in the pregnant woman by encouraging her to agonize over all of her food decisions. I would think that stress could have the opposite intended effect by actually causing high blood pressure.
  • The Brewer Diet is a lot of food. It is not natural or healthy for women to eat more than they feel hungry for. There is some concern that the caloric requirements of the Brewer Diet may grow overly large babies in women who are adequately nourished.
  • The high amounts of protein in the Brewer Diet may put stress on some women's kidneys, if their kidneys are over-taxed, and women usually do not know whether or not their kidneys are over-taxed.
  • There are many, many women who have followed the Brewer Diet and still gotten pre-ecampsia.
  • Claiming that the Brewer Diet prevents pre-eclampsia equates to patient-blaming and making women feel like their pre-e diagnosis is their fault.
Instead of promoting a specific one-size-fits-all diet, why don't we focus on a few sound nutritional principles?


Sound Nutritional Principles for Pregnancy:
  • Try eating frequent small meals during pregnancy. This may help with nausea (no guarantees, though) and will accommodate for the decreasing size of your stomach as your baby grows. Listen to your body about how much to eat.
  • Avoid eating too many high-carb and sugary processed foods (white bread, baked treats, etc.) and opt instead for whole grains--oats, multigrain bread, brown rice, whole wheat pasta, etc.
  • Include protein in your diet each day, but don't worry too much about getting a specific number of grams. Meats, eggs, dairy, beans, and nuts can all be good sources. Many beans and nuts are not complete proteins by themselves, but create a whole protein when eaten along with whole grains. (Edited to Add: Experts now recommend 60-80 g of protein for pregnant women. If you don't eat much meat and/or dairy, you may want to keep track to be sure you're getting enough.)
  • Include a variety of colorful fruits and vegetables in your diet, especially ones where the flesh is colorful, not just the skin. Leafy greens are especially healthy--romaine lettuce, spinach, kale, etc.
  • Include healthy fats and oils in your diet, but remember that a serving of fat is very small and there is some fat in other foods you are eating.
  • Have water on hand throughout the day and drink enough that you are not getting thirsty.
If you are at risk for high blood sugar, have insulin issues, have been diagnosed with gestational diabetes before, or have a history of large babies, there are other considerations for you.

20 comments:

  1. Any popular diet should be questioned really, never mind the ones specifically tailored to pregnant women. Healthy eating outside and during pregnancy should be a given, but not everyone has the same metabolic needs. I was just as skeptical when I read the 'What To Expect' pregnancy book to see just how terrible it was and came to the chapter about monitoring food intake. They make it seem like eating a bowl of icecream is going to kill your baby. Completely bogus. I'm glad you brought up the same problem with this diet fad.

    ReplyDelete
  2. Hypnocritical? Can you define please?

    ReplyDelete
  3. Susan, "hypnocritical" was a typographical error, which I have corrected to say what I meant, which is "hypocritical." I must have been distracted when I wrote this post.

    ReplyDelete
  4. I think you need to stick with teaching preschoolers because it is obvious that prenatal nutrition and research is not your forte. Wow is this wrong! Contact Joy Jones for a proper education on The Brewer Diet and the evidence that has backed it up long before Dr. Brewer presented it. Yikes, hun!

    ReplyDelete
  5. I don't think the personal comments above are necessary. I may not agree with this assessment of the Brewer diet (I have had personal success and success with it as a teacher) but I think Brittany would be a great childbirth educator someday. It is good to look at what we may take for granted critically and research it. The Brewer Diet for the most part is in line with her "Sound Nutritional Principles for Pregnancy." I hope that every pregnant momma will have the wisdom to take the information she is given and then do her own research.

    ReplyDelete
  6. Thank you, Anonymous. This is the first time I've had somebody be so blatantly rude to me on my blog, but I'm sure if I keep writing stuff like this, it won't be the last. My critique of the diet came almost straight from the words of a CPM who I respect for her lack of bias on pregnancy and birth issues. The Brewer Diet is often touted as some sort of panacea for all pregnancy complications, and I don't think it is that simple. I think Dr. Brewer had some good ideas about nutrition, and of course I know he did research on nutrition before creating the diet, but there has been NO peer-reviewed research on women using his diet itself, so we do not know if the claimed benefits actually exist or if there are are any increased risks of negative outcomes associated with the diet. I don't think we should throw the baby out with the bathwater, though. The "nutritional principles" I wrote here ARE basically a very simplified, lower-stress version of the Brewer diet, which I think are more adaptable to individuals and give women more freedom to listen to their bodies, and isn't that what childbirth education is all about?

    ReplyDelete
  7. Great post... and thanks for mentioning me. As you already know, this is one of the topics near and dear to my heart, having had PE myself and having had several clients with it during pregnancy and even a couple who got PE postpartum.

    Natural Birth Blog (NBB), constructive criticism is fabulous, but your snotty comment was not helpful at all. How about you cite some sources? How about YOU go visit the PE websites that speak, in detail, about the Brewer Diet and its ineffectiveness... and possible danger to women at risk of kidney disease/failure in pregnancy.

    Much more is known about PE than when Dr. Brewer experimented on this patients decades ago. It is far, far too simplistic to believe PE is a nutritional "disease." And I am right there with Brittany when it comes to the double-standard of demanding medical care ONLY use evidence-based care, yet midwifery care slides by using homeopathy, herbs... and the Brewer Diet... all without a shred of *scientific* evidence that they, not only work, but are safe to use in pregnancy.

    When you've known women who've been *meticulous* with the Brewer Diet and sat with them near death from PE/Eclampsia, *then* come talk to me about the causes of this too-often fatal disease. Believe me, I *wish* it was as easy as eating 80 grams of protein a day.

    ReplyDelete
  8. Too often when people say "evidence based" they mean "evidence I want to believe." It's a source of great frustration to me as I try to navigate being a doula and eventually a CBE. I believe in natural childbirth.

    ReplyDelete
  9. Sorry, editing error.

    I believe in natural childbirth, but that doesn't mean I believe that "natural" always means "safe" or "best."

    ReplyDelete
  10. Judi tinkelenberg CNMMarch 22, 2011 at 11:33 PM

    Dr. Brewer himself refuted much of the information that he touted in "his" diet. Shortly before he died, he told me that all the information on high protein diets preventing pre eclampsia was found to be incorrect. His words in fact were "You midwives aren't still telling women that eating a lot of protein prevents preeclampsia are you? We now know it is all about taking fish oils that is more important for that" Of course, we all know that the Cochrane data base and other studies have since refuted the role of fish oils in preventing pre eclampsia as well, but the point is, information on nutrition in pregnancy changes all the time as newer studies are done. Dr. Brewer's original research was done on VERY UNDERNOURISHED young women who found that dietary improvement improved outcomes in general. Adding extra protein for THEM probably made sense (as does adding calcium for women that are truly deficient), but this can't be extrapolated out to include women that aren't bordering on starvation due to a complete lack of resources as was the case with the clinic in which Dr. Brewer worked. Do pregnant women need more protein than when they are not pregnant? Depending on their pre pregnancy protein intake the answer is probably ""yes to support added demands of fetal growth, uterine growth, increased blood volume etc. The amount found to be most beneficial is 60-80 grams. If women are consuming this much before pregnancy, they need no increase. Does a diet high in protein, calcium, fish oils, vitamins C,D or E or any other food prevent preeclampsia? At this time thee is no evidence to support any of these claims, Anecdotal evidence has limited value, and there are those who swear by eating 100-200gms of protein as miraculously working for this reason, there are many of us who have found that there is no such benefit and no real evidence either.

    ReplyDelete
  11. I've always been a big fan of balanced nutrition, and the Brewer Diet never seemed particularly balanced to me. Way too much protein for many moms. I do feel that nutrition early on in pregnancy (or even before pregnancy), perhaps while the placenta is developing, could help to prevent all manner of pregnancy illnesses, but no diet is going to be able to prevent them 100%.

    ReplyDelete
  12. Thanks for writing this. I'm the child of hippies. I grew up on a farm, drank raw goats milk after I weaned, and have always been healthy as a horse. When I got pregnant with my first, I chose a practice of midwives. I had massive protein craving throughout my pregnancy, ate tons of eggs, meat, milk, yougurt, almonds, whole grains, fruits and veg. Took fish oil, and b vitamins. And developed severe preeclampsia and delivered my baby at 29 weeks.

    If there is a reason I developed preeclampsia, it probably has something to do with being born into a family of hypertensives.

    I've really been amazed at the amount of vitriol in the natural birth community towards women, like myself, who got preeclampsia and say "I didn't do anything to cause this and it could happen to anyone including you." I know a lot of that reaction is due to fear and denial, I was probably in the same place before I got sick.

    I had to give away my copy of Birthing From Within because I couldn't stand that it had that section telling women that the Brewer's diet would prevent pre e.

    ReplyDelete
  13. Thanks so much for writing this, I've only recently heard about the Brewer Diet and was researching it this morning and honestly I was having anxiety just thinking about how stressful it would be to follow it exactly every day. I have 2 toddlers and trust me I don't need the stress. Reading your blog has confirmed to me that I already eat what I need to without following a diet plan during pregnancy.

    ReplyDelete
  14. One thing we do know (or think we know) about pre-eclampsia is exactly what Dr. Brewer stated, and that's that inadequate blood volume is the trigger for this disorder. http://jap.physiology.org/content/75/4/1566
    When placental perfusion is inadequate, the placenta produces hormones to raise maternal blood pressure and increase perfusion.
    http://physiologyonline.physiology.org/content/16/6/282.full

    Here's how I look at it: poor nutrition could certainly cause contracted blood volume, and the calories, protein, and salt intake (it's much more than just protein) of the Brewer diet insure that nutrition is adequate to support the increase in blood volume that must take place during pregnancy.

    Are there other factors that could cause hypovolemia (low blood volume) during pregnancy and trigger the pre-eclampsia process? Of course. Do we fully understand these? No. Will excellent nutrition prevent pre-e in these cases? Not necessarily, but it may improve the odds.

    ReplyDelete
  15. I am a doula and apprentice midwife. I have been taught from my mentors, and passed on to my clients, the concepts of the Brewer Diet. I am now enrolled in a Nutrition course and noticed right away the stark differences in the protein and caloric recommendations of the Brewer Diet from the Recommended Dietary Allowance, Adequate Intakes, and Upper Limits (which, by the way, are updated every five years utilizing data from our much loved Chochrain Review). I believe I am experiencing a paradigm shift.

    I would like to thank you for the post. I would like to also thank Navel Gazing Midwife and Judi Tinkelenberg for their comments. Its not easy feeling like the only one in your community who has the suspicion that something within the belief system (such as a "natural" pregnancy recommendation)is just not right.

    ReplyDelete
  16. Thanks for this post. I am a CNM student and another student midwife just told me about it and "how amazing it is" and that I should check it out. Very good to read an opposing view, and very good point about evidence based care. I know as midwives we are trying to provide wholistic and alternative care options for our patients, but that is not an excuse to use bad science. thanks.

    ReplyDelete
  17. thanks for writing this. I followed the Brewer diet at the urging of my Bradley instructor and my OB and still got early-onset, severe pre-e and had a baby at 30 weeks. I had a very good diet before i got pregnant.

    ReplyDelete
  18. Thanks for the post, and for all of you who have commented. I have been enlightened. I particluraly appreciated Tara's comment. It makes a lot of sense. I followed the Brewer diet my first pregnancy. It did seem like a lot of food, but was touted as being very good, and so I followed it pretty carefully. I did get a bit relaxed in my protein intake round about 6 months or so. My midwife saw an increase in my blood pressure and encouraged me to to up my protein. Having done that, my blood pressure went back down. My midwife had at least a couple of other instances with clients who had similar results. I don't know if those other clients had gotten to the point of peeing protein or not. Would we have gone to the PE stage if not increasing our protein intake? I don't know. It seems more than coincidence though. It is good to have some guidelines for pregnancy nutrition, which I know has been stated. It seems a little simplistic to have expectant women just listen to there bodies and eat accordingly. It seems most people don't listen to their bodies. Anyone ever been "stuffed" after going to a buffet? ;) Or on the other side, "forgot to eat"?

    As I said, I really like Tara's comment indicating that there could be many causes of PE only one of which is poor nutrition. This is good to know. I hope I'm not being too simplistic in my comments, I am glad for all of the info. here. Thanks again.

    ReplyDelete
  19. Thank you so much for writing this! I am a doula, and about to become a Hypnobabies instructor, as well as a Bradley class veteran and mother of 3. 12 years ago, I followed the Brewer Diet, and ended up developing pre-e with a visual disturbance at 36 1/2 weeks. I was risked out of my home birth and insisted on a 24 hour urine collection, which confirmed the diagnosis. I called my doula trainer, my Bradley instructor and a couple of the town's other Bradley instructors for advise. One Bradley instructor, known for churning out militant students and doctor-bashing, told me to "go home and eat more eggs". I was devastated. My pre-e symptoms started at 31 weeks, and progressed slowly, monitored by my midwife, but I had no protein in my urine and my blood pressure was normal until the visual disturbance. The next morning I had +4 protein and bp of 180/110. I think being careful with my diet helped, but I had hyperemesis from 5 weeks until 28 weeks, so none of it stated down anyway.
    After researching the Brewer diet, I found the out-dated, poorly controlled studies to back it up. I stopped recommending the diet to clients and friends because I cannot, as a professional, recommend something with no real backing to pregnant women.
    Dr. Brewer's "Blue Ribbon Baby" site is gone BTW.

    ReplyDelete
  20. So late to the party here :) But thanks for posting this. As a former RN I've been frustrated by the lack of evidence based practice in the medical field. I am finding pregnancy and childbirth is especially rife with belief systems people build around their practices. I have a feeling this has to do with the difficulty in ethically obtaining and conducting good studies with pregnant women. So you have pointed out that many BELIEVE in the Brewer Diet and pointing out that its subject to scientific inquiry runs contrary to their world view. Any time I am in the situation to confront this kind of belief, I run the risk of aneurysm. Right now, I am pregnant and post weightloss surgery. The brewer diet has me stressing about diet again. Maybe its better because I'm actively trying to find a happy medium. I really prefer a whole food, balanced diet and don't want to spend my time obsessing about protein. This is the best summary I have found regarding protein intake in pregnancy from the World Health Organization: http://apps.who.int/rhl/pregnancy_childbirth/antenatal_care/nutrition/glcom/en/

    ReplyDelete