Brittany: So I’ve been in clinical practice over 10 years now. And, you know, I started out seeing all sorts of clients, whoever I could get initially, and then I really took an interest into pediatric nutrition. You know, I was starting with my own family, my son was struggling with some health issues, mainly gut issues. He had FPIES, so food protein-induced enterocolitis. He was later, when he was three years old, diagnosed on the autism spectrum. That really triggered my interest to follow the pediatric nutrition path. So for years and years, I saw kids, and one day I literally just woke up and thought, “You know what? In that clinical case-taking, I’m asking so many questions about how is the pregnancy? You know, what’s the breastfeeding history? What’s the family history?” And what I realized was so much of what I was saying was preventable. So had we done proper preconception care, had we addressed the gut microbiome, had we modified risk factors in pregnancy through nutrition and lifestyle, the outcome for that child could have been so much better. So I turned to prenatal, postnatal nutrition.

Andrew: You’ll be delivering a webinar for Designs for Health. What will you be talking about? I guess you’ve already mentioned it there, but is there anything else that you’ll be expanding on?

Brittany: Yeah. So we will be looking at key diet and lifestyle factors that impact fertility and also pregnancy outcomes. And also, obviously, the outcome for the infant and the child as well. We’ll be looking at supplementation and dosages for what should be in a prenatal multi and then, of course, my add-ons for fertility as well. We’ll also be taking a deep dive into which pathology tests that you as a nutritional or naturopathy clinician should be asking for and should be checking at regular intervals, both during fertility, preconception, and pregnancy. And of course, post-birth. Let’s not forget our post-birth mothers.

Andrew: Yes, please. I mean, there’s something that really needs a shakeup in the modern healthcare system. But, Brittany, like when you’re talking about changing your practice from concentrating on pediatrics, which already is, to something like prenatal care, which isn’t yet, how do you get your patients to find you during that period of prenatal care if you like?

Brittany: So sadly, a lot of these couples come to me after they’ve been trying for quite a while. I’d say the minority of my clients are people who are being proactive and just coming to me because they want to do the best they can, and they want to have the best start for their, you know, fertility journey. Most people are coming because they’re having trouble conceiving, or they’re having pregnancy complications. I wish I could see people, you know, from the very, very beginning, so they could potentially prevent all these complications and added stress. But usually, as most clinicians listening will know, people usually come to you when there’s a problem or something’s wrong.

Andrew: Yeah. Yeah, that’s right. But it’s good to see though that there are more people who are proactive in their approach to fertility care. You know, I guess people…certainly there is no denying that we are living in a more toxic world. There is no denying. Indeed, just on my phone, 20 minutes ago, I was looking at a very orthodox paper talking about toxicity affecting newborns. So these pollutants are here. They are definitely ubiquitous. And then we need to figure out what is their effect and how can we prevent, you know, dire consequences for that. So, part of that, you know, we’ve got mandates on folic acid. We’ve got recommendations for pregnant women with iodine, for instance, but not necessarily a multivitamin. And yet there’s ubiquitous nutritional deficiencies throughout our whole society. This is on the Australian Bureau of Statistics. So I’m going to ask you, how do you approach the utilization of nutrients even from something as simple as a multi?

Brittany: I think the first step is always testing. So knowing the individual’s requirements that’s, yeah, obviously, step number one. We have these IDIs, and we have these sort of public health recommendations, which is fine for majority of the population. Look, we’re not going to be able to help everyone, so I think it’s important that the public health message is clear and that it’s there. But when we’re working with people one on one, I do think there is a bit of leeway for making recommendations slightly outside of the IDIs or the recommended amount. So the biggest example of this is folate, and we know that folic acid is so important for the prevention of neural tube defects. But, you know, the standard 400 micrograms of synthetic folic acid for everyone may not be the best fit. So there’s a whole range of people that need a higher dose and that may need methylfolate as well.

So I think the first thing you want to do is check their serum folate. You also want to know their methylation status. I often check their homocysteine levels. You want to know their B12 status as well because we know that B12 and B9 or folate compete for absorption and that if you have an imbalance of those two, you create a bit of a methyl trap. And you run into this issue of unmetabolized folic acid, which can really be a big issue with causing immune problems, immune dysregulation, and potentially autism. There’s some literature coming out with that as well.

Andrew: Look, thank you for saying that because this was an eye-opener for me from Carolyn Ledowsky who is, by the way, doing research on this exact topic. And I’m putting my hand up here. I was one of the doubters. I was one of them. Because back in the olden days, when all you had was folic acid, I used to get results, and I could see homocysteine decreasing, but because I wasn’t measuring other parameters, there was no real measure of what is going unnoticed. This is such an interesting topic, Brittany. Can you take us through this folic acid trap a little bit more?

Brittany: Yeah. Oh, I feel like I’m not gonna do it as much justice as Carolyn would…

Andrew: You will be fine I’m sure.

Brittany: …for sure. So basically, in literature, it says that up to around 200 micrograms of supplemental folic acid is the upper limit that your body can absorb without it circulating unmetabolized. And we’re recommending pregnant women to have 400 micrograms. So you can assume that most pregnant women are walking around with unmetabolized folic acid in their blood. And the problem with this is it creates a methylation trap in that methylation cycle where B12 can’t be absorbed. And I might be butchering this. I do feel like Carolyn will be better to explain the exact mechanisms. You know, I’m quite good on the clinical application and all of that kind of stuff, but the exact mechanisms I’m not very good at explaining, Andrew.

Andrew: I think you did very, very well. I have to ask though, you were talking about homocysteine at assessment and B12 and holo…forgive me, activated B12 or active B12, which is holotranscobalamin as well as measuring folate. Can you measure unmetabolized folic acid in common labs these days? And second question, second part of the question is, do you look at genes?

Brittany: I do look at genes and, you know, I certainly look at MTHFR for a patient if they’re willing to pay for the test, or if their GP is willing to order it. But in terms of unmetabolized folic acid, there is actually no test at the moment, and I know that there was a recent paper that came out where they were basically assessing what we know and what we don’t know. And they said that basically, the next step is to find a better marker for unmetabolized folic acid.

Andrew: Right. So a surrogate marker. And is that why you look at homocysteine?

Brittany: Yeah.

Andrew: Is there anything else like, I don’t know, methylmalonic acid or anything like that?

Brittany: I do like MMA for a more accurate B12 result, but I think it’s taking it all-in context. It’s looking at the homocysteine. It’s looking at the folate. It’s looking at the B12 and piecing it all together.

Andrew: Yep. Yeah. Something that you said earlier, by the way, talking about how folate and B12 compete, it also seems to explain part of the picture, if you like, of why some people have extraordinarily high levels of B12 when you measure them, and they’re not necessarily on a supplement. What’s going on here?

Brittany: So some people have extraordinary high levels of B12.

Andrew: Hmm, yeah. And my previous knowledge or thoughts on it were that it was either driven by inflammation, or there might be something quite sinister happening in the body, you know, whether it be an autoimmune disease or something like that. But I think there may be another explanation for this folic acid trap for instance?

Brittany: Yeah, potentially. And then the other thing that I think about is, you know, we talk about folate for methylation, we talk about B12 for methylation. There are so many other cofactors that are just are important. And I feel like choline is one of the biggest forgotten vitamins, well, when it comes to prenatal supplementation and the methylation cycle, and a lot of prenatals don’t even contain choline. And I really think that’s a huge downfall for a lot of them. And there’s new literature coming out saying that basically closer to 1,000 milligrams a day of choline is, you know, a more optimal dose. In Australia, we have an adequate intake, which is 440 milligrams, but for that optimal methylation, for that optimal brain function for the, you know, child’s long term health, that 1,000 milligrams a day, I think it was 960 milligrams a day, during pregnancy is certainly more optimal.

Andrew: Gotcha. And what about the forms of choline? In mostly a solid tablet you’ll get choline bitartrate. But then if you get the choline on its own, it’ll normally be in a capsule as phosphatidylcholine or a liquid. Do you have a preference? Does it matter? Or do you just concentrate on the dose of choline?

Brittany: I quite like phosphatidylserine, which can be converted into choline in a mother who’s stressed. I really like it for that stress regulation application. But usually, if I’m looking at a prenatal multi, I am just looking for choline bitartrate. And, you know, I’m really looking at that dose because we know that there aren’t a lot of foods that contain choline. So, you know, things like eggs, peanut butter, brussel sprouts, you know, they have reasonable amounts of choline, but nowhere near enough to get you closer to that 1,000 milligrams. So you really want a high choline prenatal.

Andrew: A lot of these prenatals as well they have really transitory? No, that’s not the right word. A poor amount..a very low level of especially things like B vitamins. Indeed, there’s been almost a paranoia around B6. Really weird. Is there any sort of specific things that you look for with the B vitamins?

Brittany: Yeah. I mean, especially with B12 and folate, I like them to kind of be around a similar dose. Usually, it’s 500 micrograms of B12, and maybe there are 500 to 400 equivalent folates. B6, I’m quite comfortable dosing up to 100 milligrams per day throughout the whole pregnancy. And certainly, the literature says that up to 200 milligrams a day of B6 is safe and doesn’t cause… So the big issue with B6 is peripheral neuropathy. But again, B6 is so essential for progesterone production. It’s great for morning sickness, actually. It’s one of the key things that I give for morning sickness, and I do like it in that P5P form for morning sickness, and it’s important to the methylation cycle.

Andrew: That’s really interesting. You’re speaking about morning sickness and P5P because it’s sort of activated there. Oh, okay, I like your thinking. That’s really good. Okay, so can we…

Brittany: I only found one paper that said…Sorry. I was gonna say, I only found one paper that said P5P was better than regular pyridoxine, but I kind of went with that because I really do believe in activated vitamins.

Andrew: Well, if you take just like an energetic approach, and I’m pretty physically biased, but that sort of TCM type of approach to nausea, where the liver is involved and B6 has to be dephosphorylated before it’s rephosphorylated into P5P, and P5P is therefore not restricted to, but it’s more suited to people who have got liver complaints. You know, people are on a lot of medications, people are suffering from chronic fatigue, blah, blah, blah, and people with nausea because the liver is involved in that sort of cycle of nausea. I think it quite makes good sense.

Brittany: Yeah, that’s a really good way of putting it.

Andrew: Oh, thank goodness. Okay, so let’s talk…forgive me, so we have to talk about doses when we’re talking about everything here to give some sort of practical hints and tips. So is there anywhere where you think we have to be cautious of? Like, you mentioned 200 milligrams of B6. I’m totally with you there that there’s been this real weird paranoia about B6. I can still remember, back in the old days, that when my wife and I got married we went to the States. Yes, it was pre-COVID. And in the States, I bought a multivitamin. Now, forgive me, I’m gonna talk international unity, not retinol equivalents. You divide by three, basically, to get the same amount. But I can still remember on the multis in Australia, the TGA said that anything over 2,500 IU was toxic and would cause birth defects. And yet I bought this multi in America, and on the label, it said anything over 10,000 should be avoided. And yet I brought that multivitamin back to Australia. And I used to show my patients here. I’d say, “Somewhere over the Pacific Ocean, this multivitamin turned toxic because it’s got too high of vitamin A.” Now, you know, the TGA has sort of woken up and they’ve loosened that restriction a lot. But can you take us through the actual reality of the toxicity of vitamin A?

Brittany: Yeah. And the World Health Organization says that you can have up to…now I’m going to talk in IU’s, 10,000 IU’s, which is…I think that’s 3,000…it’s about 3,300…

Andrew: Three thousand three hundred.

Brittany: …Or 3,000…yeah, in micrograms. And, you know, I’ve been thinking about this a lot, Andrew. You know, we’re so phobic of vitamin A, and I do wonder…I mean, it’s so important for iron metabolism, and how many pregnant women are we all seeing that are iron deficient in pregnancy? Either iron deficient at the beginning of their pregnancy or iron deficient, you know, by the time they reach the end of their second trimester. It’s so important for immune regulation as well. What role is it playing…? I mean, Australia has got one of the highest rates of allergies? This is me just hypothesizing. There’s actually no research to back this up.

But, you know, it’s so important for immune regulation. What role is our underdosing, or our phobia of vitamin A playing on our immune systems, and our children’s immune systems? And I think that’s absolutely right. It’s just Australia, really, that’s not doing up to 10,000. And there’s not a lot of food sources of vitamin A unless you’re eating livers and things like that, which I really don’t advise because of the environmental contamination component of it. If you’re eating, you know, carotenoids and a bit of butter here, and having some vitamin A in your supplement, it’s really not a big issue.

Andrew: Yeah. Look, I’m totally in agreeance with you. I think we’ve become way too paranoid and we’re forgetting the science. I get the issue that the TGA has about safety, about being the Vanguard for safety. And let’s face it, the TGA is the gold standard for the world with safety, so let’s give them that. But if we’re darn [SP] going to be talking science, let’s talk science, not a restriction of such. Let’s talk that real science. So that’s my only sort of issue would B6 and vitamin A and things like that is like let’s talk about this, you know. Let’s not just smooth it over with a really paranoid dosage. So can we talk a little bit about fertility and things like that?

Brittany: Mm-hmm.

Andrew: You know, we talk about supplements, but obviously, supplements are just that they’re not maintenance [SP]. So we have to talk about diet. How do you modulate diet in helping couples, not just females, but couples achieve fertile ground?

Brittany: So I think if I were to sum it up in one sentence, it’s basically to eat a Mediterranean-style diet. And unfortunately, it’s not the type where you’re eating pasta and drinking red wine. So the key thing is, I think, to start with healthy fats. So you want to avoid those trans fats, which, unfortunately, in Australia, we’re a bit behind on the Americans. It’s usually the other way around I feel like. But our labelling of trans fat content in food is not the same standard as they are in America. So in America, you have to label exactly how much trans fats are on the label, whereas in Australia, it’s just it’s not there. So people really need to have the information to navigate where the trans fats are coming into their diet.

So if you’re going to avoid trans fats, you need to replace it with good fats, and of course, omega-3 fatty acids are the way to go. I always minimize saturated fats, and I guess this might be a little bit controversial because I know a lot of pracis recommend, you know, high cholesterol, because cholesterol is a precursor to steroid hormones, etc., etc. But I do find that, you know, not eliminating, but reducing saturated fat is beneficial for my fertility patients. Yeah, yeah. But really getting those omegas up is really key for sperm health, for egg health. Yeah. So avoiding bad stuff or the good stuff. So seafood, but that’s also controversial.

Andrew: Okay, but when we’re speaking about omega-3s, we’re talking about fish. And that in itself has its own hazards with regards to the increased amount of toxicants that they’re finding in fish. There’s now even recommendations, particularly overseas, for pregnant women not to have so much fish. So therefore we are either dependent on a fish oil supplement, which have shown to be extremely pure, or we’ve got to look for other sources of omega-3s, which aren’t quite as efficient in the EPA, DHA conversion, right? So what do you use?

Brittany: What do I use? I mean, some of my clients who enjoy eating fish, eating things like sardines and anchovies and all those smaller species, and they’re having them, you know, two, three times a week, but they’re certainly avoiding the big fish like the, you know, swordfish, some of the bigger tuna, you know, catfish, etc., etc. I still use omega-3s from fish oil, but I’m really picky about brands and where it’s sourced from, and the testing that they do as well. I do feel like fish oil is a safer option than actually eating fish. Although, you know, there’s so much more to fish than just omega-3s, right? There’s the iodine component, and so many women are iodine deficient. There’s a selenium component. But unfortunately, our food supply is very polluted. You know, it’s not just mercury now, it’s plastics. You know, it’s all sorts of stuff

Andrew: Fire retardants. Yeah.

Brittany: Yeah, it’s not a very clean food source. So unless you have a really good supplier, yeah, it’s tricky.

Andrew: Yeah, yeah, I’m with you. So I think for anybody listening out there, if you can’t validate through your supplement supplier, there’s the P-Anisidine level, the TOTOX level, then you’ve got the contaminants that are there and they minimize those. And they get like a combined level of freshness. They look at dioxins, they look at flame retardants in the fish oils. This can all be assayed now. So I think this sort of stuff should be as a minimum to ensure our patients, particularly our pregnant women and our fertility patients, to ensure that we’re giving them really the best start in life.

Brittany: Absolutely, and a good fish oil shouldn’t smell fishy either. That’s how you know that it’s not oxidized or off.

Andrew: Yeah, that’s right. Exactly. Right.

Brittany: Yeah, so there should be no issues taking it. And I have played around with the idea of algal…Oh, sorry. I have played around with the idea of algal DHA as well, but at the end of the day, it’s just too many capsules. You know, by the time my pregnant ladies have their multi, their probiotics, and then, you know, fish oil algal DHAs, it becomes a lot of tablets to get that same dose that’s in fish.

Andrew: Yeah, forgive me, I cannot understand why the TGA, I think they still do, restrict the algal form of these omega-3s to only contain DHA not EPA. I don’t understand that restriction. It’s not a safety restriction, so what is it? Because overseas you can get algal EPA, DHA forms. So what’s the issue? There certainly doesn’t seem to be the issue of bioconcentrated toxicants in algal sources. Although I get that, you know, we should always be assaying for other toxicants as well.

Can I ask, Brittany, obviously we’re talking about the good things that vitamins do and things like that? But is there any cases that you find…actually, no, forgive me, before I ask that question, I’ll ask about the gut. How important is the gut to make sure that that’s healthy and a longer correct programming, that sounds really computer-ish, to help with proper fertility and give the child the best chance in life with regards to say allergies?

Brittany: Yeah. So I’ve read something interesting over the weekend, actually, that you are passing on more microbial cells to your child than what you are human genetic cells.

Andrew: What?

Brittany: And I wonder…yeah. And when you think about it, you’re also passing on your microbiome, and your partner’s microbiome, onto your child as well, just through the mode of, you know, delivery and bringing them into your household and all of that kind of stuff. But in terms of genetic programming and immunity, we know that probiotics are so important. So my go-tos are the LGG and the Bifidobacterium species for that specific immune programming. But we also know that diversity is really important as well. So I do recommend a broad-spectrum probiotic, and particularly from 30 weeks, I’m looking for a probiotic with Lactobacillus salivarius in it as well to help with that mastitis prevention because the last thing we want is…