Preventing eclampsia (metabolic toxemia of late pregnancy): an interview with Tom Brewer, MD.

Townsend Letter for Doctors and Patients; 11/1/2004; Puotinen, CJ  http://www.highbeam.com/library/docfree.asp?DOCID=1G1:123709104&ctrlInfo=Round20%3AMode20b%3ADocG%3AResult&ao=

Despite a century of research, American medicine offers as little today for the prevention and treatment of eclampsia (traditionally called toxemia) as it did a hundred years ago. This progressive and potentially fatal condition remains a leading cause of miscarriage, premature birth, and infant mortality in the United States and around the world. An estimated 50,000 women die every year from eclampsia.

The condition's name is derived from the Greek word eklampsia, which means a sudden flashing or onslaught, an appropriate term for the rapidly developing system failures that characterize this medical emergency. Hypertension, severe edema, and protein in the urine are the signature symptoms of eclampsia, which adversely affects the brain, kidneys, liver, and lungs. Other common symptoms include headaches, nausea and vomiting, decreased urine output, changes in mental status, agitation and confusion, pain in the upper right abdomen, shortness of breath, sudden weight gain, and visual impairment. If the condition progresses to its final stage, the mother-to-be develops seizures or goes into a coma.

Extensive research notwithstanding, the cause of eclampsia remains a medical mystery. The preferred treatments are bed rest, dietary restrictions, prescription diuretics, and medication for hypertension. The preferred cure is delivery of the infant, usually months premature, by induced labor or Caesarian section.

To Tom Brewer, MD, these methods are worse than useless; they're dangerous. The cause of eclampsia and its simple cure, he says, have been known for decades. Beginning in the 1920s and '30s, medical journals have published dozens of scientific studies based on clinical observation as well as statistical and epidemiological studies showing that eclampsia is an easily prevented nutritional disease. (1-75)

Now retired, Dr. Brewer enjoys a career as a lecturer and nutritional counselor for pregnant women. Thanks to electronic publishing, the books What Every Pregnant Woman Should Know and The Brewer Medical Diet, both of which describe his discoveries and recommendations, are available as ebooks at www.pregnancybooks online.com. The Blue Ribbon Baby Pages website (www.blueribbonbaby.org) details his dietary guidelines, along with case studies, scientific references, and other information for pregnant women. In addition, Dr. Brewer maintains a free information hotline at 802-388-0276.

Interview with Tom Brewer, MD

Q: How did you become interested in the importance of nutrition for a healthy pregnancy?

Dr. Brewer: I learned about the problem of eclampsia, or what I call the metabolic toxemia of late pregnancy, before I went to medical school. I was married and had a new baby, and we had a neighbor from Russia who often described conditions in that country and the toll they took on pregnant women. (7) Times were very hard, food was scarce, and many women died of hemorrhage or convulsions. The Russian people at that time believed such events were the will of God and that women were meant to suffer in childbirth, but my neighbor believed the problem was simply a lack of food.

So in 1947, when I got into medical school at Tulane University, which was at that time in the middle of a New Orleans slum, I saw the problems he described first-hand.

In my first year, I went to a lecture given by James Henry Ferguson, (16) an instructor who came from Chicago, where he had worked with W.J. Dieckmann, a professor from Germany. Professor Dieckmann believed that protein deficiencies and malnutrition were the cause of most of the problems he saw in Chicago. He was then chair of the Chicago Lying-In Hospital.

When Ferguson came to work at Charity Hospital, where Tulane then had an obstetrics ward, he gave several lectures on OB/GYN topics, and one was about toxemia pregnancy, as it was called in those days. He said we were faced with a disease that's common in poor people, common in people who don't have prenatal care, common in diabetics, and common in women who have twins.

As he listed the risk factors, I had a gestalt, a moment of insight. I already had in mind the observations of my Russian neighbor. Now I was hearing an expert talk about the risk factors of toxemia. I realized that this problem could only be due to one thing, and that's poor nutrition.

Q: Did any of your professors make this connection?

Dr. Brewer: None of them did. They were surrounded by poverty and malnutrition but, as far as I know, none of them ever considered that these conditions might have anything to do with the problems we saw every day, like worms in children, miscarriages, and various diseases. My professors definitely did not share Ferguson's views. They were primarily surgeons. They were interested in performing C-sections, removing fibroids and ovarian cysts, performing hysterectomies, and so on.

So there, in my first year of medical school, I developed an antagonistic view.

When I started working with patients, I was on a ward where there were 20 beds with women who had this disease, toxemia pregnancy. Their blood pressure was up, their bodies were swollen, and they had a history of not having a decent diet. I learned this by talking with them. That's considered anecdotal, not verifiable, not from a clinical trial, not statistically significant, and so on. I've never been big on the statistical approach because each individual mother is important. Each one faces her own troubles.

Anyway, I got onto this nutrition connection, and I became obsessed with it. It became a central area of thought for me.

For my internship, I went over to Baylor College of Medicine in Houston. There was a lot of toxemia there, too.

Q: Were you able to help your patients?

Dr. Brewer: Yes. As an intern, I studied them. I did blood tests and liver function tests, and I asked them questions. As a result, I made several observations. For example, the blood gets thicker in toxemia because the woman gets dehydrated. (22-24,35,37,49,52,57) That's why diuretics are so dangerous in pregnancy. Also, toxemia is directly related not only to a lack of fluid in the body but a lack of protein, (5,6,14,18,38,45,54,56) salt, (13,21,36,42,44,46,47,49,59,69) vitamins, (4,18) minerals, (28,56) and other things. (7-9,14,30,56,62,63,65-68) Keep in mind that during my internship, there were only about 50 known nutrients. Now more are being discovered all the time. There may be a thousand nutrients. So I didn't know exactly how nutrition prevented toxemia, I just knew that it worked.

After my internship, I went to Lallie Kemp Charity Hospital, which was a rural hospital north of New Orleans. After a year there, I went into general practice in Fulton, Missouri. I had a partner, Dr. Jim Hill, who went with me from our General Practice residency at Lallie Kemp. Jim Hill and I were both studying toxemia. We did not restrict salt, we did not restrict food or weight gain, we did not use diuretics, we encouraged our patients to eat protein, and we had very healthy women giving birth to healthy babies. Prior to our arrival at Lallie Kemp Charity Hospital, 25% of the pregnant women there had toxemia. To go from a situation where one out of four women has hypertension, edema, and protein in the urine to where there's none at all was what I call a learning experience. It's not something I read in a book. We used the same approach in our General Practice in Fulton, where we worked for three years. Out of 100 births, we had only one toxemic patient. She was a poor woman who came to us from a shack on the Missouri River easement. She was severely toxemic because of her deficient diet, and she had received no prenatal care at all.

Then I went back to take a residency in obstetrics and gynecology, primarily to study this disease further and to try to prove the methods by which it occurred. The only professor who would support me in this effort was the same Jim Ferguson who had lectured at Tulane in 1947. By this time, he had become a professor and chairman at the University of Miami's Jackson Memorial Hospital in Miami, Florida.

I asked him to give me a research fellowship. He said there was no money for research on nutrition and pregnancy but to come anyway. In some ways that was a mistake because it's difficult to be a full-time resident and do research on the side, but I did it. I was there for four years, working with Jim Ferguson on a number of projects that interested him. We studied the placentas to see whether there was bleeding or what I now call toxic abruptio placentae, where the placenta just breaks loose, usually in the middle trimester. (33,57) This happens in the time span just beyond the spontaneous abortions that occur in the first trimester.

That condition seems to be increasing today, along with toxemia itself and all kinds of child development problems. (29) I'm convinced that low birth weight, (1,7,8,11,12,18-20,27,29,33,38,41,60) premature birth, (21,58) lowered intelligence, (32,34) birth defects, (70) neurological dysfunction, (20,26,27,32,34,40) and many other problems--all have a nutritional cause. I suspect this is true for autism, idiopathic respiratory distress syndrome, cerebral palsy, and sudden infant death syndrome as well. The individual nutrient that's involved varies from patient to patient, but they all fit under the umbrella of malnutrition. These conditions are studied as though each is a disease unto itself, unrelated to everything else, but they're not. They are what happens when you starve a pregnant woman or when she by circumstances, starves on her own or when some idiot doctor puts her on a low-calorie, low-salt diet and prescribes diuretics, which are the worst things you can give her. (22,37,42,44,46,49,52,58) Low blood volume, which is the inevitable result of dehydration and the use of diuretics, contributes directly to eclampsia, premature birth, and low birth weight. (23,35,36,38) And now there's a whole group of hypertension drugs that have come out in the last 10 to 15 years. These drugs just ravage women. They cause direct damage to all of the cells in the mother's body, particularly to the liver, a little to the kidneys, and then to the placenta and fetus.

As a result of all this, my point of view or medical philosophy is not at all compatible with that of the people who are running things. I believe American medicine took a very bad turn when it let pharmaceutical companies take over.

Q: What is your general advice to pregnant women and to women who hope to become pregnant?

Dr. Brewer: I tell them to stay away from prescription drugs, eat good-quality protein, eat a variety of foods, drink plenty of water, don't try to lose weight, and don't restrict salt. I tell people to trust their taste buds and salt their food to taste. If your food tastes bland, or if you get leg cramps or feel tired and weak, just put a little more salt on your food. I'm always amazed by modern medicine's prejudice against salt. (21,22,36,37,42,46-49,52,58,69,71) I used to watch a lot of tennis, and I'd see players out in the hot sun with cramps in their legs, and their doctors would advise them not to use salt tablets. There were even experts who would say you shouldn't take salt when you're running in a marathon. That attitude has changed a little, but salt still has a terrible reputation. It's because the anti-salt crusade lasted for so many years. There was this prevailing attitude that salt was poison, that it caused hypertension, that it caused strokes, that it caused diabetics to go to pieces, and that it just shouldn't be used. Sodium even disappeared from medical books. You'd find other minerals described as important or essential, but sodium wasn't even listed.

You could say that the best advice I can give women is to ignore the experts and take responsibility for their own bodies and their own babies. Our culture has a long history of treating women as inferior, and that's especially true in medicine. Women who educate themselves, listen to their bodies, stay away from prescription drugs, and feed themselves the way healthy women have fed themselves for thousands of years, not the way Americans are feeding themselves today on low-fat, low-protein, high-carbohydrate, low-salt, low-calorie foods--those enlightened women are going to have healthy, full-term pregnancies with no complications.

Protein, good foods, salt, and water have protective effects, and prescription drugs have all kinds of adverse effects, yet the irrational, unscientific use of restrictive diets and prescription drugs in pregnancy continues. Doctors tell their patients to eat low-protein, low-calorie, low-salt diets, even though these have been thoroughly documented as being harmful to both the mother and her unborn child. (4-6,8,10-12,14,16-18,22,36-38,40,42,46,47,50,55,58-64,67,71,75) In addition, the blind use of "weight limitation" in pregnancy management has been shown in studies of thousands of pregnancies to be dangerous because it leads to malnutrition, especially in the last half of gestation. (31,40,46,49,52,54,58,59,62) Pregnancy is simply not the time to restrict food.

Q: What is the Brewer Diet for a Healthy Mom and Baby?

Dr. Brewer: I called this my Brown Bag Prenatal Nutrition Lecture. (65-67,74) A pregnant woman should drink one quart (four 8-ounce glasses) or more of milk every day. In addition, she should eat two eggs plus one or two servings of fish, chicken, lean beef, lamb or pork, or any kind of cheese.

She should also eat one or two daily servings of fresh, green, leafy vegetables such as mustard, collard, or turnip greens, spinach, lettuce, broccoli, or cabbage; five servings of whole-wheat bread, corn tortillas, or cereal; a piece of citrus fruit or a glass of orange or grapefruit juice; a large green pepper, papaya, or tomato; and three or more pats of butter.

The diet also includes five servings of yellow-or orange-colored vegetables five times a week; liver once a week if you like it; a whole baked potato three times a week; all the water and fluids you need to prevent thirst; and all the salt you need to make your food taste good. These are not optimum amounts, these are minimums, and you go from there.

You need 80 to 100 grams of protein every day to prevent toxemia. I never used this figure when describing the diet because it was hard enough to get patients to remember a quart of milk and two eggs every day, plus salt to taste. That was the diet's foundation. It is a little more difficult to reach your nutritional goals if you are a vegetarian or have food allergies, but you can do it. For protein, you can substitute vegetable proteins as long as they are "complete" proteins and you don't have trouble digesting them. Rice with beans, peanut butter, tofu, nuts, and seeds all provide protein.

This diet will prevent toxemia, other maternal complications, and all kinds of neurological, physical, motor, and behavior abnormalities in the child. I tested this diet for over 30 years on thousands of patients and those who followed it never had eclampsia, anemia, abruption of the placenta, severe infections of the lungs, kidneys, or liver, low birth weight babies, premature birth, or miscarriage, and all of their children were healthy.

It takes courage to adopt this diet because the concept behind it, that malnutrition is the cause of toxemia and other diseases associated with pregnancy, remains very unpopular in American obstetrics.

Q: Are pregnancy problems increasing in the United States?

Dr. Brewer: They are. Pregnant women in our country have become less healthy than pregnant women in other countries. Increasing numbers of premature or "low birth weight" babies are being born. The US is starting to resemble Third World countries that have extreme poverty and famine. That is because our doctors don't know anything about nutrition.

Instead of focusing on food, they focus on drugs. They keep looking for a remedy that will cure toxemia. They prescribe diuretics for edema, hypertensives for high blood pressure, and drugs that suppress the appetite for weight loss. Those do nothing to prevent or reverse Metabolic Toxemia of Late Pregnancy, they just make it worse.

People have been recommending supplements, too, like calcium, fish oil, and an aspirin a day, all of which are supposed to prevent toxemia. But research published in the medical journals show that these aren't effective, either. (76-79,81) Calcium, aspirin, essential fatty acids, and other supplements can't take the place of good food.

Meanwhile, doctors are doing what they've been taught, and it isn't working. I think this is why so many obstetricians have been sued for malpractice. If they were delivering full-term healthy babies with no complications, no one would be suing them. But the premature birth rate just keeps increasing, and so do all the other problems that result from inadequate nutrition.

Improving the diet is the most effective and least expensive way to prevent toxemia and insure the delivery of full-term, healthy babies. The dietary guidelines I developed in the early years of my medical practice are still working well. When I went to Richmond, California, and ran the prenatal clinics of Contra Costa County from 1963 to 1976, over 25,000 women followed these guidelines with success. (51)

These clinics had never offered any kind of nutritional counseling. The women would be weighted, they'd have their blood pressure checked, and they'd have a urine test, but no one ever asked them what they ate. I always asked. That's the thing I did that was different. The reason I could do that was because I was the only OB doctor at the time. My methods were unconventional, but I was the person in charge, so we did it my way.

I was taught in medical school that if a pregnant woman gains over two pounds a week, she's about to die. That's how intense the fear of weight gain was. But I never told a single woman that she was gaining too much weight. The only reason I discussed weight with them at all was to be sure they were gaining enough, that they weren't too thin. Winslow Tompkins (8,18) studied this in the 1940s and '50s both in West Virginia and Philadelphia, and he discovered that the patient who does not gain weight is at high risk for toxemia. His work had a profound effect on me as I studied this problem. He worked for the government as head of the MIC (Maternal Infant Care) program, which was a forerunner of the WIC (Women, Infants and Children) program. The MIC program didn't work because so many doctors who worked in it ignored Tompkins' good advice and did what they were taught in medical school instead, so they got poor results. He had the right ideas, he articulated them and got the programs set up, but the program's doctors, who were scattered around the country, followed the advice of pharmaceutical companies and ignored nutrition. They prescribed diuretics and other drugs, and their patients suffered.

After I finished my five-year contract with the clinics of Contra Costa County, I stayed on and worked with the people who were hired to do a statistical study. I'd spent two years in Richmond, then two years at the county hospital in Martinez, and then went to Pittsburgh, California, so I had worked at all three of the major county clinics. The data showed improvement in every category. There was a period during which the Pittsburgh clinic continued to use conventional methods while I used nutrition in the Richmond and Martinez clinics, so we used the Pittsburgh clinic as a control. The Pittsburgh clinic had 10 times more hypertension in first pregnancies than the Richmond and Martinez clinics. Those findings were published in the Journal of Reproductive Medicine as a preliminary report. (51) A team of eight government researchers spent three years going over 5600 cases. They studied every blood pressure reading, every urinalysis, and every other test recorded on the charts, and they verified our results.

Throughout my 12 years in these clinics, I met face-to-face with about 7,000 pregnant women. Many people came to sit in on my lecture discussions to see if I was a charlatan, nutrition faddist, quack, or nut. Some of these visitors were from Planned Parenthood, March of Dimes, State colleges, or UC Berkeley, or they were public health nutritionists. At the end of the discussion, after the patients had left to be examined, someone would always say, "That's a very nice presentation, Dr. Brewer. Your advice isn't likely to kill any pregnant mom or fetus. But do you think these people can understand it and apply it in their daily lives?" My patients might have been poor and mostly black or Mexican, but they got my message.

Five years after one woman gave birth to a healthy 8-pound baby, she came back because she was pregnant again. She told me that when she was there the first time, she was illiterate, but she had since gone to school and learned how to read and write. I was very happy for her, as that was quite an achievement. Then I asked her what I had told her to eat, and she rattled off the list that had kept her healthy five years before. I said, "Isn't it amazing? Even when you didn't know how to read or write, you knew more than most professors at the University." And that was the truth.

Q: What about high-risk patients, like women who are overweight to begin with?

Dr. Brewer: They're at risk only if they starve themselves trying to lose weight. Developing babies need a certain amount of nourishing foods every day, and that's what my diet provides. Many overweight women lose weight or keep from gaining weight while maintaining a healthy pregnancy just by focusing on the right foods. Average-size women often gain as much as 50 pounds on these foods. That's what Catherine Zeta-Jones did when she gave birth last April to a 6-pound, 12-ounce baby. Pounds of weight gain or loss are not the essential question for the health of mom and baby. What matters is the adequacy and quality of the food the mother eats, the amount of water she drinks, the amount of salt she consumes, and whether she avoids harmful drugs. Women who eat well and gain 40 or 50 pounds usually lose the weight soon after birth because much of the weight gain in a healthy pregnancy is due to the mother's expanded blood volume and the weight of the baby, placenta, and amniotic fluid. But if you gain weight eating junk food, the baby can't use any of it for nourishment and it gets stored as fat, which is much more difficult to lose. I used to see women at the charity hospital who lived on sugar and starches, which are empty calories. They were overweight, but they gave birth to underweight babies, and they often developed toxemia. I had a 400-pound patient once who ate six candy bars every morning for breakfast. She was at risk not because of her weight but because of her terrible diet.

The most serious risk for an overweight patient is the doctor who assumes that if you're pregnant and have even slightly elevated blood pressure, you have toxemia and should stay in bed, stay away from salt, take diuretics and hypertension medications, try to lose weight, and get ready for a C-section or induced labor.

The symptoms of toxemia or eclampsia can seem to develop rapidly, but they actually progress gradually, with enough warning for the patient to reverse the trend. Midwives who follow my diet call this treatment "Turn It Around." That's exactly what they do, they turn the condition around. Most doctors believe that once eclampsia begins, it can't be corrected. That's an aphorism or a received wisdom, a shared belief, but it isn't true at all. One of my mentors, Maurice Strauss, (5) discovered in the 1930s that women who had severe morning sickness throughout their pregnancies often went into convulsions, but when he put them on high-protein diets as therapy, they stopped vomiting and experienced a normal pregnancy.

I've found that the only time hypertension doesn't respond to nutritional therapy is when it's a preexisting condition that isn't caused by diet, and that's unusual. Almost all pregnant women who have hypertension and edema have it because they aren't getting enough protein, other nutrients, salt, and fluids.

Another problem pregnant women face is gestational diabetes testing. Medical doctors assume all pregnant women are at risk for diabetes, so they test their blood sugar, but they don't use normal values to diagnose the results, they use a reference range based on test results from undernourished pregnant women. As a result, the glucose tolerance test (GTT) values for pregnancy are too low for women who follow the Brewer Pregnancy Diet. Women who are well-nourished are able to meet their babies' glucose needs without lowering their own, but most pregnant women in America exhibit lower plasma glucose levels than the rest of the adult population because they are not eating well. Doctors who insist on giving a GTT to women on the Brewer Pregnancy Diet should use the new diagnostic criteria established for non-pregnant individuals to avoid making an incorrect diagnosis of diabetes.

If a patient insists on taking the GTT, she should load up on starchy foods such as bread, potatoes, rice, pasta, and sugars for three days prior to the test. These carbohydrates help the liver store glycogen in preparation for the all-night fast imposed by the GTT protocol. This glycogen reserve can then stabilize the blood sugar during fasting. Without carbohydrate loading, you exhaust your liver's storage of glycogen overnight and may test out with a diabetic curve when, in fact, you are not diabetic at all, you're just temporarily glycogen-depleted.

Q: What about other risk factors, like smoking or exposure to environmental pollution?

Dr. Brewer: I always told pregnant women to try to refrain from smoking, drinking alcohol, and using street drugs, and I still think that's sensible advice. But when one of my patients told me her sister smoked two packs of cigarettes a day through five pregnancies, and all of her babies were full-term and weighed eight pounds, that convinced me more than ever that nutrition is the most important factor.

Environmental factors are much more likely to pose a risk to women and developing babies who don't receive enough nutrition than they are to fully nourished women and babies.

Q: Scientists recently announced that certain proteins secreted by the placenta rise significantly in mothers experiencing eclampsia, suggesting that these proteins cause eclampsia. (80,82) Are these findings significant?

Dr. Brewer: Research that's focused on "genetics" or speculative biochemical enzymatic equations never addresses the underlying cause of an illness or condition. I don't doubt that unusual proteins are produced by a starving fetus or a starving mother, but those proteins don't cause eclampsia. They're just another symptom. Inadequate nutrition causes eclampsia.

In a New Zealand sheep experiment published in the journal Science, none of the ewes on a normal diet had premature births, but half of the ewes that were put on a moderate weight-loss diet at the time of conception gave birth prematurely. (83) The researchers decided that a mother's diet before and around the time she conceives can profoundly influence the length of pregnancy, and they called this a stunning scientific breakthrough. This is what I mean about medical researchers knowing nothing about nutrition. It's obvious, but they didn't have a clue.

Sheep have been studied before, and they have shown all the same symptoms and problems that humans have. In one study, pregnant sheep were starved at the very end of their pregnancies, and most of them died. Other researchers have found that sheep giving birth to twins, triplets, or quadruplets are more likely to have toxemia than those giving birth to single lambs.

This is true for humans, too. A woman pregnant with twins has to eat for three, for herself and each of her babies, and a woman pregnant with triplets has to eat for four. It isn't easy to do this, but the more good nutrition a woman can provide for her developing babies, the healthier they will be. (72)

Q: One problem women face is that they may not be planning to get pregnant, or they may not know they're pregnant until several weeks have passed. Yet their diet at the time of conception is as important as their diet in the following nine months.

Dr. Brewer: That's exactly right. If you're a woman of child-bearing age and you're remotely interested in having children, the only sensible thing to do is improve your diet now. Pregnancy is a test of the body. This is why it's so hard on the poor. It's also hard on the fashionably thin. It's worse if you smoke, too, but the most important factor is nutrition. If you make bad food choices, you're more likely to have complications during pregnancy and give birth to a child who has serious health problems. But if you ignore the advice of most doctors and eat the foods that support the developing fetus, you'll have a problem-free pregnancy and a healthy child. And if you're already pregnant, it isn't too late to improve your baby's health. Even in the final months of pregnancy, improving the maternal diet has a beneficial effect on fetal growth. (30)

Q: How does your Pregnancy Hotline work?

Dr. Brewer: I enjoy hearing from pregnant women and the people who support them, and my hotline at 802-388-0276 is reserved for that purpose. Most of the women who call learn about me from the Blue Ribbon Baby Pages at www.blueribbonbaby.org.

I like to hear their stories, and I enjoy offering a second opinion. Everyone who is in the business of helping women and babies, including midwives, obstetricians, pediatricians, lactation consultants, childbirth educators, and doulas, should know the truth about nutrition.

My dream is that one day every woman will know how easy it is to have a strong and healthy baby.

References (annotated by the author)

1. Acosta-Sison, Honora. "Relation between state of nutrition of the mother and the birth weight of the fetus: A preliminary study." Philippine Islands Med. Assn. 9:174, 1929. The incidence of low birth weight was found to be nearly 10 times higher among poorly nourished women than in those determined to have good nutritional status.

2. Mellanby, Edward. "Nutrition and child-bearing." Lancet 2:1131, 1933. Discussed the need for protective nutrients in human pregnancy and that eclampsia is a metabolic common nutrition-deficiency disease. He noted: "nutrition is the most important of all environmental factors in childbearing whether the problem be considered from the point of view of the mother or that of the offspring."

3. Theobald, G.W. "Discussion on diet in pregnancy." Proc. R. Soc. Med. 28:1388, 1935. Refuting various speculations about the causes of toxemia, the author concluded that its etiology is malnutrition.

4. Ross, Robert A. "Relation of vitamin deficiency to the toxemia of pregnancy." So. Med. J. 28:120, 1935. In North Carolina, he identified role of malnutrition and poverty in eclampsia and other human reproductive casualties.

5. Strauss, M.B. "Observations on the etiology of the toxemias of pregnancy." Am. J. Med. Sci. 190:811, 1935. Internist at Harvard recognized the role of proteins and related deficiencies in the etiology of eclampsia. Toxemia subsided in women placed on a 260-gram protein, well-balanced diet, with injections of vitamin B.

6. Dodge, E., and Frost, T. "Relation between blood plasma proteins and toxemias of pregnancy." JAMA 111:1398, 1938. The authors observed that low-protein diets, often prescribed by physicians for the treatment of toxemia of pregnancy, increased the severity of the disease. They successfully improved the condition with diets consisting of six or more eggs daily, one to two quarts of milk, lean meat, legumes and other nutritious foods; and they directly linked toxemia with low serum albumin and inadequate protein intake.

7. Ebbs, John, et al. "The influence of prenatal diet on the mother and child." J. Nutr. 22:515, 1941. The low-birth-weight incidence was 2.2 percent in the best nourished group.

8. Tompkins, Winslow T. "The significance of nutritional deficiency in pregnancy: A preliminary report." J. Intl. Col. Surg. 4:147, 1941. Eradicated pre-eclampsia/eclampsia, low birth weight, and stillbirth at Philadelphia Lying-in Hospital. Infant mortality was reduced to 4 per 1000 births.

9. Balfour, M. I. "Nutrition of expectant and nursing mothers. Interim report of the People's League for Health." Lancet 2:10, 1942. Food supplementation and nutrition education contributed to significant reductions in toxemia, perinatal death and maternal mortality.

10. Burke, Bertha S., et al. "Nutrition studies during pregnancy." Am. J. Obstet. Gynecol. 46:83, 1943. Confirmed nutritional thesis of the etiology of eclampsia and demonstrated the protective effect of adequate nutrition on the mother, fetus/neonate and infant.

11. Cameron, C. S., and Graham, S. "Antenatal diet and its influence on stillbirths and prematurity." Glasgow Med. J. 24:1, 1944. In both prospective and retrospective studies, maternal malnutrition was found to cause low birth weights, stillbirth and infant mortality.

12. Antonov, A. N. "Children born during the siege of Leningrad in 1942." J. Pediatrics 30:250, 1947. Warcaused famine led to widespread incidence of infertility, amenorrhea, a low birth weight incidence of 49% and infant mortality of 500 per 1,000 live births.

13. Ross, Robert A., "Late toxemias of pregnancy: The number one obstetrical problem of the South." Am. J. Obstet. Gynecol. 54:723, 1947. This grim report showed that the toxemia incidence and infant mortality were high among the malnourished poor.

14. Mitchell, J., et al. "Dietary habits of a group of severe preeclamptics in Alabama." J. Natl. Med. Assn, 41:122, 1949. Toxemia was found to be closely associated with inadequate nutrition. When placed on a sound diet providing, on the average, 124 grams of protein per day, all of the toxemic women improved.

15. Toverud, Guttorm. "The influence of nutrition on the course of pregnancy." Milkbank Mem. Fund Qtr. 28:7, 1950. Proper nutrition reduced the incidence of low birth weight to 2.2% and halved that of stillbirths.

16. Ferguson, James H. "Maternal death in the rural South: A study of forty-seven consecutive cases." JAMA 146:1388, 1951. The author described the severe poverty and malnutrition of toxemic women in rural Mississippi.

17. Hamlin, Reginald. "The prevention of eclampsia and preeclampsia." Lancet 1:64, 1952. Eradicated eclampsia by an aggressive nutrition education program in a prenatal clinic, Women's Hospital, Sydney, Australia.

18. Tompkins, W. and Wiehl, D. "Nutrition and nutritional deficiencies as related to the premature." Pediatric Clin. No. Am. 1:687, 1954. Weight at birth was highly associated with prenatal nutrition, weight gain during pregnancy, and pre-pregnancy weight. The low-birth-weight incidence among women who received protein and vitamin supplementation, gained substantial weight during pregnancy, and were not underweight at conception was less than 2 percent. In contrast, 24% of the babies born to women most likely to be malnourished were underweight at birth.

19. Jeans, P. C., et al. "Incidence of prematurity in relation to maternal nutrition." J. Am. Diet. Assn. 31:576, 1955. Low birth weight was found to be highly correlated to prenatal nutrition.

20. Knobloch, H., et al. "Neuropsychiatric sequelae of prematurity: A longitudinal study." JAMA 161:581, 1956. A well-controlled and meticulously designed longitudinal scientific study linking low birth weight to neurological dysfunction and impaired cognitive potential.

21. Robinson, Margaret. "Salt in pregnancy." Lancet 1:178, 1958. Classic study at St. Thomas Hospital, London. Among 2000 pregnant women, those put on a "low-sodium diet" experimentally had over twice the incidence of toxemia and significantly higher perinatal mortality than those told to "eat more salt." This study should not have been done because it was unphysiological and needlessly harmed many mothers and babies.

22. Brewer, T. H. "Limitations of diuretics therapy in the management of severe toxemia: The significance of hypoalbuminemia." Am. J. Obstet. Gynecol. 83:1352, 1962. First published account of the threat diuretics pose to the health of mothers and their unborn by attacking maternal and fetal plasma volumes. This warning went unheeded, as the use of sodium diuretics became a routine practice in prenatal care among most obstetricians in the US.

23. Green, G. H. "Maternal mortality in the toxemias of pregnancy." Aus, N.Z.J. Obstet. Gynaecol. 2:145, 1962. Ten toxemic women died in hypovolemic shock, without excess blood loss or infection.

24. Brewer, T. H. "Administration of human serum albumin in severe acute toxemia of pregnancy." J. Obstet. Gynecol. Br. Cwlth. 70:1001, 1963. Rejected by editors of U.S. medical journals, this paper demonstrated the nutritional pathogenesis of metabolic toxemia of late pregnancy, stressing the problem of maternal hypovolemia.

25. Jarvinen, P.A. and Tarjonne, H. "Observations on the value of pregnancy care on maternal mortality and eclampsia of pregnancy." Ann. Chir. Gynaec. 53:91, 1964.

26. Knobloch, H., and Pasamanick, B. "Prospective studies on the epidemiology of reproductive casualty: Methods, findings, and some implications." Merrill-Palmer Qtr. Behav. Dev. 12:27, 1966. Maternal health is linked directly to child development.

27. Merrill-Palmer Qtr. Behav. Dev. 12:7, 1966. A continuum of neuropsychiatric disorders in this review of 49 scientific studies is associated with low birth weight and the presence of complications during pregnancy.

28. Brewer T. H. "Human pregnancy nutrition: A clinical view." Obstet. Gynecol. 30:605, 1967. Advocates application of scientific nutrition and physiology in human prenatal care.

29. Schenider, Jan. "Low birth weight infants." Obstet. Gynecol. 31:283, 1968. Documents the alarming rise in low birth weight in the US after 1950.

30. Iyengar, Leela. "Urinary estrogen excretion in undernourished pregnant Indian women: Effect of dietary supplements on urinary estrogen and birth weights of infants." Am. J. Obstet. Gynecol. 102:834, 1968. Demonstrated beneficial effects on fetal growth by improving maternal diets as late as the 36th week of gestation.

31. Singer, J. E., et al. "Relationship of weight gain during pregnancy to birth weight and infant growth and development in the first year of life." Obstet. Gynecol. 31:417, 1968. Weight gain during pregnancy is statistically related to birth weight and infant mental, neurological, and motor function. Unfortunately, the paper ignores the question of the quality of diet causing the weight gain.

32. Drillien, C. M. "School disposal and performance for children of different birth weight born 1953-1960." Arch. Dis. Child. 44:562, 1969. Low birth weight is associated with an increased proneness to handicap and a lowered IQ. Birth weight was found to influence child development more than socioeconomic background.

33. Brewer, T. H. "A case of recurrent abruption placentae." Del. Med. J. 41:325, 1969. Dietary history recorded of a woman who had two abruptions and two neonatal deaths of low-birth-weight babies in one year. After her malnutrition was corrected, she had a normal baby with no complications.

34. Winick, M., and Rosso, P. "The effect of severe early malnutrition on cellular growth of human brain." Pediatric Res. 3:181, 1969. Malnutrition during pregnancy is shown to lead to a significant reduction of brain cells in the newborn. Impaired hyperplasia of brain cells was reflected in their finding that brain weight, protein, RNA and DNA were substantially reduced in newborns of malnourished women.

35. Bletka, M., et al. "Volume of whole blood and absolute amount of serum proteins in the early stage of late toxemia of pregnancy." Am. J. Obstet. Gynecol. 106:10, 1970. Valuable observation documenting that hypovolemia and hypoalbuminemia precede hypertension and other signs of metabolic toxemia of late pregnancy.

36. Pike, R. L., and Gurskey, D. S. "Further evidence of deleterious effects produced by sodium restriction during pregnancy." Am. J. Clin. Nutr. 23:883, 1970. The consequences of sodium deficiency, such as hypovolemia and stress on the renin-angiotensin-aldosterone homeostasis, are well documented.

37. Brewer, T. H. "Human pregnancy nutrition: An examination of traditional assumptions." Aus. N.Z. J. Obstet. Gynaecol. 10:87, 1970. Exposes the incorrect ideology and dangers of the routine obstetrical practices of weight control, salt restriction and the use of sodium diuretics.

38. Duffus, G. M., et al. "The relationship between baby weight and changes in maternal weight, total body water, plasma volumes, electrolyte and proteins and urinary oestriol excretion." J. Obstet. Gynaecol. Br. Cwlth. 78:97, 1971. Total circulating protein mass correlated most significantly with infant birth weight.

39. Brewer, T. H., "Disease and Social Class," in The Social Responsibility of the Scientist. Martin Brown, ed. New York: Free Pres, 1971. Examines mechanisms by which poverty and malnutrition cause human diseases including maternal and infant morbidity and mortality. Stresses the need for primary prevention.

40. Platt, B. S. and Stewart, R. J. C. "Reversible and irreversible effects of protein-calorie deficiency on the central nervous system of animals and man." World Rev. Nutr. Diet. 13:43, 1971. Neurological dysfunction is extensively linked to malnutrition in both animal and human studies in this review of 177 works.

41. Fort, A. T. "Adequate prenatal nutrition." Obstet. Gynecol. 37:286, 1971. Proper fetal development and birth weight, the author states, are directly dependent upon the pregnant woman's nutritional intake.

42. Schewitz, L. "Hypertension and renal disease in pregnancy." Med. Clin. No. Am. 55:47, 1971. This erudite review of 100 studies demonstrated the absence of scientific validity driving a low-salt diet and/or sodium diuretics to edematous or hypertensive expectant mothers. Severely hypertensive pregnant women received 14 grams of salt daily without demonstrable harmful effects or increased blood pressures.

43. Brewer, T. H. "Human maternal-fetal nutrition." Obstet. Gynecol. 40:868, 1972. Another call for the application of physiology and basic nutrition science in human prenatal care, this paper criticizes the positions of the American College of Obstetricians and Gynecologists in this field; i.e., "nothing is known."

44. Chesley, Leon C. "Plasma volume and red cell volume in pregnancy." Am. J. Obstet. Gynecol. 112:440, 1972. Leading expert in the field of "pre-eclampsia/eclampsia" condemned the use of sodium diuretics in toxemic patients because of their hypovolemic state. Subsequently, his highly regarded chapter entitled "The Hypertensive Diseases of Pregnancy" was dropped from Dr. Jack Pritchard's edition of Williams Obstetrics.

45. Kelman, L., et al. "Effects of dietary protein restriction on albumin synthesis, albumin catabolism, and the plasma aminogram." Am. J. Clin. Nutr. 25:1174, 1972. A valuable study done on men in South Africa which demonstrates the critical role of dietary protein intake in maintaining hepatic synthesis of serum albumin. Such studies, in which daily protein intakes were reduced to 10 grams, cannot be done ethically on human pregnancies, yet they demonstrate the pernicious effects of both low-protein and low-calorie diets.

46. Lowe, C. U. "Research in infant nutrition: The untapped well." Am. J. Clin. Nutr. 25:245, 1972. Emphasizes that the abandonment of weight control, low-salt diets, and diuretics is necessary to significantly reduce the rates of prematurity and low birth weight.

47. Pike, Ruth L., and Smiciklas, H. "A reappraisal of sodium restriction during pregnancy." Intl. J. Gynaecol. Obstet. 10:1, 1972. Demonstrates that salt is an essential, protective nutrient for human pregnancy and not a "poison," as is still thought by many OB/GYN physicians in the US.

48. Foote, R. G., et al. "The use of liberal salt diet in pre-eclamptic toxemia and essential hypertension with pregnancy." New Zealand Med. J. 77:242, 1973. More clinical observations which destroyed the "salt is a killer" myth in human pregnancy.

49. Hibbard, Lester. "Maternal mortality due to acute toxemia." Obstet. Gynecol. 42:263, 1973. Reports alarming increase in maternal deaths from metabolic toxemia of late pregnancy. Most of the toxemic women had been placed on low-salt and/or low-calorie diets. Some were also given sodium diuretics.

50. Brewer, T.H. "Iatrogenic starvation in human pregnancy." Medikon 4:14, 1974. A call for major changes in current US. OB/GYN nutrition and drug practices and antenatal care. Advocates that constructive actions be taken immediately to improve human maternal/fetal and neonatal health in the U.S. and to protect all pregnant women and their unborn from the ravages of prenatal malnutrition and harmful drugs.

51. Brewer, T. H. "Metabolic toxemia of late pregnancy in a county prenatal nutrition education project: A preliminary report." J. Reprod. Med. 13:175, 1974. Data from National Institutes of Health retrospective study of 5,615 pregnancies delivered in Contra Costa County, CA, 1965-70, a 5-1/2 year period. No cases of eclampsia were found, nor were there any maternal deaths in the nutrition project pregnancies. Not one woman had a cesarean for "severe pre-eclampsia" or "hypertension."

52. Brewer, T. H. "Pancreatitis in pregnancy." J. Reprod. Med. 12:204, 1974. Another painful, often fatal complication of pregnancy linked to the use of sodium diuretics and low-sodium, low-calorie diets.

53. Brewer, T. H. "Toxemia- a disease of prejudice?" World Med. J. 21:70, 1974. Includes a review of Pathology of Toxemia of Pregnancy by H. L. Sheehan and J. B. Lynch (Edinburgh and London: Churchill Livingston, 1973). A great deal of emphasis is placed on the specific liver pathology associated with eclampsia.

54. Habicht, J. P., et al. "Relation of maternal supplementary eating during pregnancy to birth weight and other sociobiological factors," in Nutrition and Fetal Development. M. Winick, ed. New York: John Wiley & Sons, 1974. Caloric supplementation among low-income women resulted in eradication of stillbirth and a reduction of the incidence of low birth weight from 13.4% to 3.5 percent. Demonstrates the protein-sparing effects of calories from carbohydrates and fat among women on low-protein diet.

55. Shneour, E. The Malnourished Mind. New York: Doubleday, 1974. Discusses, in a conversational manner, the unequivocal causal relationship between impaired development and malnutrition during pregnancy, infancy and childhood. Refutes the myth that mental deficiency is largely caused by genetic factors.

56. Williams, Phyllis S. Nourishing Your Unborn Child. New York: Avon, 1974. A useful guide for pregnant women, containing valuable information on pregnancy physiology, the role and sources of various nutrients, and 163 pages of menus and recipes.

57. Howard, Peggy. "Albumin concentrate can be used for preeclampsia." OB/GYN News, October 1, 1974. All of the toxemic women given 50 grams of serum albumin daily gave birth to babies in good health. Infusion of serum albumin improved renal function, increased estriol excretion, prevented eclamptic convulsions, and resulted in a reduction in perinatal mortality to 1/4 the rate of the "controls" and eradication of abruptio placentae.

58. Brewer, T. H. "Consequences of malnutrition in human pregnancy." CIBA Review: Perinatal Medicine, pp. 5-6. Basel, Switzerland: CIBA-Geigy, Ltd. 1975. Discusses the role of malnutrition, including iatrogenic malnutrition, via physician-prescribed low-calorie, low-sodium diets and sodium diuretics in the etiology of metabolic toxemia of late pregnancy, abruptio placentae, low birth weight, prematurity, severe infections and brain damage in children. Another call for applied science in this field on the clinical level in human prenatal care.

59. Lechtig, A., et al. "Effect of moderate maternal malnutrition on the placenta." Am. J. Obstet. Gynecol. 123:191, 1975. Placental weight, associated with birth weight, increased with caloric supplementation, providing more evidence of the protein-sparing effect of calories.

60. Higgings, Agnes C. "Nutritional status and the outcome of pregnancy." J. Can. Diet. Assn. 37:17, 1976. Documents the value of nutrition education and food supplementation in the increasing birth weight, lowering infant mortality, and eradicating eclampsia.

61. Brewer, T. H. "Etiology of eclampsia." Am. J. Obstet. Gynecol. 127:448, 1977. Refutes the age-old myth that eclampsia is a disease limited to the first pregnancy and another myth that it is caused by an occult "uteroplacental ischemia." The well nourished primigravida, protected from hypovolemia (the real cause of "uteroplacental ischemia") all through gestation, never develops eclampsia.

62. Brewer T. H., and Hodin, Jay. "Why Women Must Meet the Nutritional Stress of Pregnancy," in 21st Century Obstetrics Now! Stewart and Stewart, ed. Marble Hill, Mo.: NAPSAC Press, 1977. Cites 143 references linking maternal malnutrition to a continuum of perinatal complications.

63. Williams, Sue Rodwell. "Nutrition during Pregnancy and Lactation," in Nutrition and Diet Therapy, 3d ed. St. Louis: C. V. Mosby Co., 1977. An excellent text book providing a wealth of information about basic nutrition science and its application on the clinical level. The first nutrition textbook to break with the traditional "nothing is known" position regarding the role of prenatal malnutrition in causing human reproductive metabolic toxemia of late pregnancy.

64. Matthews, D. D., et al. "Modern trends in the management of non-albuminuric hypertension in late pregnancy." Br. Med. J. 2:623, 1978. Challenges the traditional therapies of hypertension in pregnancy: bedrest, sedation, low-sodium diets and sodium diuretics and pre-term induction. These are shown to be of no value of harmful. The authors still exhibit no conception of the role of malnutrition in causing hypovolemia.

65. Brewer, T. H. "The 'No-Risk' Pregnancy Diet," in The Pregnancy after 30 Workbook. Gail Sforza Brewer, ed. Emmaus, Pa.: Rodale Press, 1978. Provides the expectant mother with the guidance she needs to maintain good health and give birth to a healthy, fully developed child. Valuable for women of any age.

66. Preventing Nutritional Complications of Pregnancy: A Manual for SPUN Counselors. Chicago: SPUN, 1978. A practical reference for those who wish to teach applied scientific nutrition and physiology to pregnant women. Concludes with a practical quiz of 25 questions.

67. Brewer, Gail Sforza. What Every Pregnant Woman Should Know: the Truth about Diets and Drugs in Pregnancy. New York: Penguin, 1979. Available from www.pregnancybooksonline.com. The physiological adjustment of pregnancy and how to meet its nutritional stresses to help the expectant mother maintain proper nutritional status and problems caused by conventional care. Spanish translation: Lo Que Toda Mujer Embarazada Debe Saber: La Verdad Acerca de las Dietas y las Medicinas Durante el Embarazo. Mexico, D. F.: Editorial Diana, S.A., 1980.

68. Shanklin, Douglas, and Hodin, Jay. Maternal Nutrition and Child Health Springfield, IL: C. C. Thomas, 1979. Extensive review of prospective and retrospective scientific studies, physiological and neurological evidence, and epidemiological reviews linking prenatal malnutrition to a wide spectrum of perinatal complications.

69. Lindberb, Bo S. "Salt, Diuretics, and Pregnancy." Gynecol. Obstet. Invest. 10:145, 1979. Examine's Swedish policy of treating over 10,000 pregnancies per year with diuretic drugs without any scientific basis.

70. Laurence, K.M., et al. "Increased risk of recurrent of pregnancies complicated by fetal neural tube defects in mothers receiving poor diets, and possible benefit of dietary counseling." Br. Med. J. 281:1592, 1980. Prospective and retrospective studies indicated that the second most common birth defect in the US is preventable by sound nutrition. The incidence of neural tube defects was 18% in a control group of poorly nourished mothers.

71. Gormican, Annette, et al. "Relationships of maternal weight gain, prepregnancy weight and infant birth weight." J. Amer. Diet. Assn. 77:662, 1980. A retrospective controlled study documented that weight control and salt restrictions significantly reduced birth weight and resulted in other deleterious consequences.

72. Noble, Elizabeth. Having Twins, Boston: Houghton Mifflin, 1980, 1991. Explains the increased nutritional stresses of multiple fetuses and presents practical diet adapted for multiple births.

73. "Prenatal nutritional counseling substantially reduces low birth weight deliveries." Group Health News, March 1980. A voluntary prenatal nutrition education program at a Health Maintenance Organization resulted in a 61% reduction in the incidence of underweight births in addition to a significant decline morbidity and mortality.

74. Brewer, Gall, and Greene, Janice. Right from the Start Emmaus, Pa.: Rodale Press, 1981. Incorporates the nutritional perspective on all aspects of fetal development, labor and delivery, breastfeeding, and first month after birth for mother and baby.

75. Kenefick, Madeline. Positively Pregnant. Los Angeles. Pinnacle Books, 1981. Outlines the specific role of nutrition in contributing to maternal health and fetal development, maintains an emphatic position against the use of physician-imposed restrictive diets and drugs, and discusses effective, common sense approaches in treating pregnancy-related complications.

76. Onwude, JL, et al. "A randomised double blind placebo controlled trial of fish oil in high risk pregnancy." Br J Obstet Gynaecol 109:95-100, 1995.

77. Salvig, JD, et al. "Effects of fish oil supplementation in late pregnancy on blood pressure: a randomised controlled trial." Br J Obstet Gynaecol 103:529-33, 1996.

78. Levine, Richard, et al. "Trial of calcium to prevent preeclampsia." N Engl J of Med 337:69-77, 1997. Calcium supplementation during pregnancy did not prevent toxemia, pregnancy-associated hypertension, or adverse perinatal outcomes in healthy nulliparous women.

79. Caritis, Steve, et al. "Low-dose aspirin to prevent preeclampsia in women at high risk." N Engl J of Med 338:701-705, 1998. Low-dose aspirin did not reduce the incidence of toxemia/eclampsia significantly or improve perinatal outcomes in pregnant women at high risk.

80. Page, NM, et al. "Excessive placental secretion of neurokinin B during the third trimester causes preeclampsia." Nature 405:797-800, 2000.

81. Duley, Lelia, et al. "Antiplatelet drugs for prevention of pre-eclampsia and its consequences: systematic review." Brit J of Med 322:329-333, 2001. In a systematic review of 39 trials involving 30,563 women, there were no significant differences in toxemia, preterm birth, fetal or neonatal death, and low birth weight between those who took antiplatelet drugs for prevention and those who did not.

82. Maynard, SE, et al. "Excess placental soluble fms-like tyrosine kinase 1 (sFlt1) may contribute to endothelial dysfunction, hypertension, and proteinuria in preeclampsia." J of Clin Inv 111:649-548, 2003.

83. Bloomfield, Frank, et al. "A periconceptional nutritional origin for noninfectious preterm birth." Science 2003;300:606.