Marks Daily Apple
Serving up health and fitness insights (daily, of course) with a side of irreverence.
29 Oct

Dear Mark: First Trimester Frustration, Liver Dosage, and NY Times Barefoot Piece

Being pregnant is tough – or so I hear. You’re tasked with creating a child, with actually building an entire human being bit by bit from scratch. You have to carry that child, even as it grows to seven, eight, or even nine pounds or more inside your body. And all the while, your body seems to be rebelling against “what is best.” You want to eat the best food and get the right exercise and do all the right things, but what happens when your body fights you? What are you supposed to do when all you can stomach are mac and cheese and tortilla chips? For the first section, I try to help a woman in her first trimester with these issues. Next, I discuss the question of retinol overload from dietary liver, along with whether or not we need to worry about nutrient density in other organs, too. And finally, I give my take on a recent NY Times piece on barefoot running that seemed to call its usefulness and relevance into question.

Let’s go:


I am in my first trimester and have read several of your posts on pregnancy. However, I am seriously struggling to maintain my primal/paleo lifestyle. I can barely stand the sight or smell of meat. I have been able to eat some vegetables and fruit. I have been primal/paleo for a year and love it! It seems though that my pregnant self does not love it. I am so concerned that I am not feeding my body and baby the best food as I have been giving into eating whatever I can manage to keep down. Many foods that sound appealing are foods from my childhood…mac and cheese for instance and tortilla chips. I worry that going away from primal/paleo will make this pregnancy more difficult and is not healthy for my baby. I continue to CrossFit 3-5 times per week, but not having enough good fuel has made that more difficult also. Being so putt off from meat, nuts and many vegetables is making this extremely difficult and I am at a loss as to how to handle this.  I guess I am just concerned and would appreciate any words of advice you may have.


First of all, don’t stress out about this! While nutrition is important during pregnancy, so is stress management. And not just for the health of the future baby, but also for your health, including your ability to cope with postpartum depression. So, you know, take walks, get massages, try out meditation or yoga, get your partner to give you foot and back rubs – that sort of thing. Besides, the first trimester is notoriously hard on a woman’s appetite. Things should improve as time goes on.

Make super smoothies. Invest in a good blender. Toss in some frozen fruit, ice, some milk (if you do dairy), juice, or coconut milk, some protein powder, a few egg yolks, an ounce or two of nuts, and a handful or two of leafy greens. The egg yolks will provide choline, folate, vitamin A, and healthy fat. The fruit will give you phytochemicals and vitamins. The milk will provide protein, fat, and minerals. The coconut milk will provide medium chain triglycerides. The protein powder will give you protein. The greens will provide folate and minerals. The fruit flavor should predominate, making it easier to get down. You can even toss in some fish oil without it really affecting the taste much.

Get a good prenatal. Prenatals are there to give you what you need in the (likely) event that eating healthy food is impossible or repulsive. Chris Kresser recommends Pure Encapsulations Nutrient 950 with vitamin K2. Whatever you get, make sure it contains folate, rather than folic acid.

Primalize your non-Primal foods. Let’s take your two examples – mac and cheese and tortilla chips. If mac and cheese are all you can eat, dress it up. Buy gluten free mac and cheese (usually made from rice). When you make the cheese sauce, add a few egg yolks (from a farm you trust) to the mix; you won’t even know the difference. See if you can’t handle adding some ground beef or a few ounces of baked salmon to the mac and cheese, or maybe even some chopped, steamed spinach. Get tortilla chips cooked in lard or a high-oleic seed oil. Check the nutrition label for a high monounsaturated fat content and a low polyunsaturated fat content. Instead of just eating salsa, make a nutritious dip for the chips, like guacamole. Add an egg yolk to your guacamole (trust me, it tastes good, especially if you make it from scratch).

Reduce the CrossFitting. Five times a week is too much, in my opinion, especially if you’re doing full-fledged 20-30 minute WODs. Reduce the intensity, the duration, and the volume. Stick to 2-3 workouts a week, focus on strength versus metcons, and do a lot of walking.

Eat high quality cheese as a snack. Since you’re loving mac and cheese, real cheese shouldn’t be too much of a stretch. Cheese is high in protein, fat, calcium (important for the baby’s growth), conjugated linoleic acid (if it’s grass fed, especially), and even vitamin K2 (if it’s grass-fed and aged). Pecorino romano is a nice aged choice that’s almost always made from grass-fed sheep’s milk.

Check out Chris Kresser’s guest post from a while back and focus on the foods he outlined. You may not be able to get all the “sacred fertility foods” down, but at least you’ll have something to work toward.

Dear Mark,

Liver is awesome. But how much is too much of a good thing?

Do other organs (kidneys/hearts/lungs/brains) present the same problems with regards to retinol or other vitamins?


We’ve all heard the stories about the hungry Arctic explorers who died from retinoid overdose after eating polar bear (or sled dog) liver, and almost every pregnant woman has been admonished by her doctor to avoid liver because the vitamin A can increase the risk of severe birth defects. And yes, it’s true: you shouldn’t eat polar bear liver because of the extreme retinol content and vitamin A supplementation has been linked to birth defects.

That said, polar bear liver is special; just a gram of it contains between 24,000 and 35,000 IUs of retinol. A gram of beef liver contains just 165 IUs. Lesson? Don’t eat polar bear liver.

As to the risk of birth defects from liver, that’s been overblown. Retinol from food does not have the same effect on the fetus as supplemental retinol, and even though a 1995 study proved this, “avoid liver” is still standard advice given to pregnant women. In the study, women received retinol in the form of fried calf liver, oral supplements, or intramuscular injections. Both types of supplemental retinol caused huge spikes in all-trans-retinoic acid, the primary teratogenic (causing malformations to the fetus) metabolite of retinol, while liver caused no such spikes. Levels of the birth defect metabolite were 20-times higher than baseline after supplementation.

We’ve also heard that “vitamin A causes osteoporosis.” But that’s an oversimplification that ignores the very real phenomenon of nutrient interactions. Our bodies didn’t evolve eating isolated supplements. They evolved eating whole foods, and, as Chris Masterjohn has shown, it appears that vitamin A only really becomes a problem for our skeletal health in a vitamin D-deficient state. Of course, most experts won’t ever speak with that kind of nuance, instead preferring the easy way out of making declarative statements about isolated compounds.

None of the other organs you listed contain comparable levels of retinol, but they, along with liver, are rich sources of copper and iron – two essential minerals that we need but can also overdo. Folks with iron overload disease should limit their organ intake, or at least keep an eye on their levels.

I’d stick to around a half pound to a pound of liver per week, max. A bit more if you’re eating non-ruminant liver, which is lower in retinol. Less if you’re also eating other organs (not because of the retinol, but because of the copper and potentially the iron).

Good on you for eating organs!

Thought I’d show this to you. Thoughts? I’m a barefoot runner of 3 years. I can run 30km easy. I can’t run 1 km in shoes without pain. Obviously I’m on team barefoot.

Myths of Running: Forefoot, Barefoot and Otherwise


Ultimately, by defining the “best way to run” as that which allows the runner to “use the least energy and run the fastest,” I think they miss the main point of barefoot running: to reduce injury and prolong one’s ability to run and be active. Going barefoot isn’t really about being the fastest runner around. It’s about removing a barrier between the ground and your foot to heighten proprioceptive awareness and allow your body to make subconscious adjustments on the fly. Instead of having to consciously decide to adjust your gait to avoid injury, an experienced barefoot runner will do so more quickly and with less hesitation – since that barrier to awareness has been removed or reduced. And besides, there is evidence that running barefoot or minimalist improves running economy. Anyone who’s seen Barefoot Ted trotting along a trail can attest to this. And I’d assert that you when running barefoot you don’t have to run as far (or as fast) to get the intended strength and muscle development.

Although it’d be tough to put together a study that tested for this, I also think a big advantage to barefoot running is that it’s simply more enjoyable to experience the world that way. Our feet are remarkably attuned sensory organs, with nerve endings blanketing the bottoms of our feet, just begging to be used. Ram Dass once said “If you wear shoes, the whole world is covered in leather,” and I believe it. Feeling the grass between your toes, the sand beneath your feet, and yes, even the occasional sharp rock digging into your heel is an essential (but now missing) part of the human running (or walking) experience. You won’t find that aspect detailed in PubMed, but I think it’s pretty darn important all the same.

For some people, heel striking might be the fastest way to run and win races. I don’t care about that anymore, and I’ve never claimed that. All I know is that the heel strike is the improper way to land for the bare, natural human foot. So the fastest runners in the nation land on the heel, with the foot splayed out, with pigeon toes, and so on? Great. They’re fast in spite of their form. And the millions of people who read that article aren’t the fastest runners in the nation, nor are they getting paid to go out and run. They’re running to be healthier, and I worry that looking at what the professionals get away with is only going to open up the amateurs to injury and disappointment.

Thanks for reading, folks. Take care and Grok on!

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You want comments? We got comments:

Imagine you’re George Clooney. Take a moment to admire your grooming and wit. Okay, now imagine someone walks up to you and asks, “What’s your name?” You say, “I’m George Clooney.” Or maybe you say, “I’m the Clooninator!” You don’t say “I’m George of George Clooney Sells Movies Blog” and you certainly don’t say, “I’m Clooney Weight Loss Plan”. So while spam is technically meat, it ain’t anywhere near Primal. Please nickname yourself something your friends would call you.

  1. I wanted to say a very special THANK YOU for writing this article Mark.

    I had spent several months getting rid of processed foods, then several months going low carb, until I went more primal. I had great success too, until something changed. I went two months before realising I was pregnant.

    That was two months I had turned off my successful primal eating habits, and wanted only carbs and sugar, without realising the cause.

    Reading in the comments, about how other women feel nauseous in regards to primal foods too (craving carbs instead) made me feel “normal”. I gave myself a hard time, believing I had caved back into the lifestyle which had previously made me sick.

    Now I realise, my body had it’s own programing it had to stick to after millions of years of evolution. So thanks for airing the subject!

    Chris wrote on November 1st, 2012
  2. Ugh, huge sympathies. I got pregnant in June having been primal (and feeling amazing)for just 4 months. Did great for the first couple of weeks then the food aversions kicked in and I totally went off meat, eggs and veg. Could manage some fruit but basically existed for 4 months on rice krispies, toast and ginger ale. So not primal. I’m 3rd tri now and things are improving but I can still take or leave meat and can’t face veggies. Did manage a scrambled egg the other day. I need to get back off the gluten for the sake of my digestive system but still really struggling at the moment, once pregnancy is over and breastfeeding established I’ll be back onto primal living for sure!

    Hannah wrote on November 2nd, 2012
  3. Ugh… Pregnancy aversions…. I had them really badly with my first pregnancy pre-primal, and was hoping to avoid this this time around due to a better diet, but so far, it’s not going great. I was really glad to have Mark’s “blessing” to just do the best you can. I’ve been experimenting with healthy carb-like baking and wonder if Callie might find some recipes she could tolerate in the same vein: think almond flour “focaccia”, coconut flour muffins and breads, etc. This morning, I ate some leftover pumpkin bars (a recent recipe on Elana’s Pantry) and I think that was not too bad a breakfast for my queasy tummy: with pumpkin, eggs, coconut oil, etc., it was filling and full of good nutrition, too, but felt like I was eating cake!!

    Good luck, Callie, I know how hard it is!!

    E. wrote on November 7th, 2012
  4. I just have to put it down here that raw egg yolks are a big no no for pregnant women! I’m all about the green smoothies but if protein intake is your issue look into protein powder or maybe silken tofu but no raw egg! (I’m in my 1rst tri for baby #2)

    Niche wrote on December 3rd, 2012
  5. You are telling the pregnant woman to eat A LOT of egg yolks in her food. I was alarmed to read this because pregnant women are NOT supposed to eat uncooked egg yolks, it can be very harmful to the baby if something is wrong with those yolks. This was the first post I read from you and was very disappointed. Get your facts straight before telling a pregnant woman what to eat. You could do a lot of damage.

    informed wrote on June 4th, 2013
    • Doesn’t say uncooked. It says add them to the hot food, which will cook them.

      greggrok wrote on June 4th, 2013
      • Don’t know how you make your smoothies, but most of mine don’t involve anything hot. I agree that adding them to the cheese sauce for mac-n-cheese would be fine since they’d get cooked, but wouldn’t dream of putting them into a smoothie and consuming raw while pregnant.

        I can definitely sympathize with the others who had to forgo their primal diets while pregnant. I’m currently 9 1/2 weeks and am having a hard time with meat, as well, so if a particular meat sounds good for a meal, I’m happy and go with it. Usually, the thought, smell, and especially taste of meat causes me to gag (or worse). The things that have consistently sounded good to me the last few weeks are apples, carrots, citrus, and potato salad. I figure none of those are that terrible (even with the white potatoes in the salad) and is better than wanting sweets, so I’ve been rolling with what the stomach is happiest accepting.

        I’m fortunate and usually manage to hold the small amounts of what I eat down. The couple of things that really seem to work for me are:
        1. take the prenatal at bedtime (any other time of day caused major nausea – apparently, it’s the iron in it)
        2. drink lots of water (or juice if it sounds better)
        3. become a grazer – instead of eating full meals, I eat in snack portions throughout the day, so a fruit/spinach smoothie for the drive to work, then a serving of yogurt about 90 minutes later, then an apple after a few hours, etc. Keeps the stomach from getting too empty, which tends to increase nausea.

        Z wrote on June 10th, 2013
  6. I realize this is an old post, but I’ve been struggling with the first trimester (this is my second pregnancy, and the morning sickness is worse this time around) and have had a very hard time sticking to the Primal diet. I’m not stressing about it, though, and remain gluten-free.

    I’ve noticed that when I do have carbs with a meal (gluten free bread or rice) that I have more energy and generally feel more like myself, so I will continue eating these things as necessary.

    Monika wrote on April 4th, 2014

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