Thoughts about Pre-eclampsia
I am still wrestling with the comments on my blog piece on pre-eclampsia and how to respond to them. The more I read and think about it, the more I see the complexity of this issue.
The commenter who began, ‘Come on, people, wake up!’ is a little simplistic when she says “A healthy diet and lifestyle, which includes lots of fresh organic produce, plenty of fluids, salting food TO TASTE with NO restrictions on salt intake, and most importantly Adequate, high-quality PROTEIN will prevent pre-eclampsia every time.” She is right about restrictions: there have been studies that demonstrate that salt, calorie, and protein restriction are not helpful and may in fact be harmful. And it is unfortunately true that, despite this evidence, some physicians persist in counseling pregnant women to restrict these nutrients or to lose weight during pregnancy. There have been a lot of studies looking at the effect of supplements (calcium, anti-oxidants, etc) on the development of pre-eclampsia, and the evidence seems to show that such supplementation does have a positive effect in populations with poor nutrition. I would deduce from this that good nutrition may have a positive effect and, conversely, bad nutrition may increase the risk of pre-eclampsia.
However, I say the commenter is simplistic for two reasons. First, not every woman has the possibility of eating ‘lots of fresh organic produce ‘ and adequate, high-quality protein. Organic produce is high-priced produce, and high quality protein is high-priced protein. Only the most fortunate women have space for a garden, or a nearby farmer’s market, or even a Whole Foods or other natural food store where they can afford to shop. Also only the most fortunate women have the basic knowledge of good nutrition that it takes to eat well. We may shudder when we see what many people pile into their grocery carts and how often they go to the fast food outlets, but bad food is a fact for many Americans. These people are probably not seeking out home birth; they get their prenatal care, when they can get it, in public health clinics and have their babies in public hospitals, frequently with certified nurse-midwives. I think this difference in the populations that we serve as home-birth or hospital midwives explains a lot of the difference in attitude toward serious, infrequent, but devastating complications of pregnancy such as pre-eclampsia, HELLP syndrome, fetal growth restriction, and so forth. They occur so rarely in optimally nourished women, but they do occur, scarily often, at the other end of the spectrum.
Secondly, there is no evidence that dietary manipulation is not harmful to a pregnant woman or to her baby. There was a recent study that suggests that a protein-rich, low-carbohydrate diet in late pregnancy may stress the offspring. Rebecca Reynolds (University of Edinburgh, UK) and her colleagues followed-up the ‘Motherwell babies,’ a group of children born in Motherwell in the late 1960s whose mothers were advised to eat 450 g of red meat per day and to avoid carbohydrate-rich foods in an attempt to avoid pre-eclampsia.
The offspring, who are now in their late 30s, were tested for levels of stress hormones before and after stressful tasks, including public speaking and mental arithmetic. Reynolds’ team found that the more meat the mother ate while pregnant, the higher the levels of cortisol in their offspring. There is some evidence that people with high cortisol levels are at increased risk of developing high blood pressure and diabetes in later life.
“This study adds to increasing evidence for the importance of the maternal diet and suggests that one of the ways in which it can have these long-term effects is by permanently altering stress hormone levels,” said Reynolds. “Given the recent popularity of low-carbohydrate, high-protein diets, such as the Atkins diet, these data also suggest that these diets should be avoided during pregnancy.” (Source: 8th European Congress of Endocrinology; Glasgow, UK: 1-5 April 2006)
One article I read while trying to find some answers, “Strategies to Prevent and Treat Pre-eclampsia: Evidence From Randomized Controlled Trials,” (Villar, Abalos et al, 2004) concludes after searching the medical literature for quality research studies that the risk for pre-eclampsia has not shown to be affected by any of the following:
- nutritional advice in pregnancy
- protein and energy supplementation
- calcium or magnesium supplementation
- fish oil supplementation.
Protein and salt restriction have been shown to be harmful. In a study on Vitamin C and E supplementation (anti-oxidants) in very high-risk women, there was a large statistically significant decrease in the risk for pre-eclampsia in the supplemented group. Perhaps if the women who did not receive supplements had ‘lots of fresh organic produce ‘ and adequate, high-quality protein, they would have fared better.
The studies on treatment are even less conclusive. Certainly, there doesn’t seem to be ANYTHING in the literature about taking 12 eggs in 12 hours and repeating as necessary to treat pre-eclampsia once it has developed! This theory is the legacy of Dr. Tom and Gail Brewer and their high-protein diet. It is taught as gospel in many midwifery schools. As far as I know, it has never been put to the gold standard test of a randomized controlled trial with a diverse population of women.
Finally, there is just no good research to either support or refute the idea that diet has an impact on pre-eclampsia; anecdotal evidence is not enough. And herein lies the real problem. The ‘evidence-based’ midwives roll their eyes at the ignorance of the ’12 egg’ midwives and the “12 egg” midwives” sigh at the ignorance of the “evidence-based” midwives. This needs to change, and it is beginning to do so. MANA has a strong Division of Research and has collected and published data on the safety of home birth in a highly respected, peer-reviewed, mainstream medical journal. Certified nurse-midwife researchers have focused increasingly on facets of the midwifery model of care, looking at low-tech interventions such as perineal support (or not). Wouldn’t it be terrific if the ACNM Division of Research and the MANA Division of Research could get together to design and carry out a study of the possible benefits of high protein intake to reverse the progress of pre-eclampsia in its early stages? If this really works, it needs to be available to women all over the world, not just a select few. If if doesn’t work, midwives should not advise or encourage the women they care for to do it.
Postscript: My original posting about Ananth Karumanchi, the researcher who isolated a soluble protein named FLT in the blood of women with pre-eclampsia, was essentially about the discovery of a marker for the disorder, and didn’t address prevention or treatment. It provides a small but important piece of the puzzle. The researchers continue to look at FLT, hoping to use it to identify high-risk women before the condition develops, and eventually to prevent it and to treat women who do develop it.