Postpartum and Breastfeeding The Science of Nutrition

Dietician-Approved Strategies For PMAD

Steph Greunke

Table of contents

  • Intro
  • PMAD Misconceptions
  • Why Do Nutrient Deficiencies Happen?
  • Key Nutrients to Support Mental Health
  • Are You Okay?
  • References

0 min read

Thanks to Steph Greunke for her guidance in compiling the research for this post. Steph is a registered dietitian, a certified personal trainer, certified in maternal mental health (PMH-C), and a mama of two boys who. Founder of the Postpartum Reset Program, Steph can be found at stephgreunke.com.

Intro

Pregnancy and postpartum involve massive life changes that affect your physical and emotional health. A number of factors are at play when it comes to the state of your mental health during the turbulent stages of becoming a mama, including your nutritional status.

To be abundantly clear, nutrition is only one component of managing Perinatal Mood and Anxiety Disorders (PMAD) and is never intended to replace medical care, rather to supplement medical care.

But, with a lot of things out of your control during pregnancy and postpartum, nutrition is one thing you can influence. There are specific nutrients, and specific nutrient deficiencies that can impact your mental health. We believe wholeheartedly that information is empowering, and knowing about ways that you can influence your health is needed. 

With that in mind, this article is intended to help empower you on nutritional support for mental health in pregnancy and postpartum. You are not alone, mama. We hope this information helps.

Note: If you are feeling symptoms of PMAD, please reach out to a licensed provider for support. You can find resources and local providers here.

PMAD Misconceptions

Before we get into the discussion on nutrients, let’s clear up some common misunderstandings about PMAD.

PMAD can begin at any time during or after pregnancy 

You might think the window of time for PMAD is the first few months after birth, and that is when it is most common. According to the Journal of Obstetrics and Gynecology, “the prevalence of PPD appears to peak at 2–6 months following delivery, and as many as 14.5% of postpartum women may experience a new depressive episode within 3 months after delivery.”

But the reality is, symptoms of PMAD can begin any time during or after pregnancy, including after a loss or while weaning - even if that is 2+ years after birth.

PMAD comes in many forms

Education around PMAD is lacking. Some women will be handed a pamphlet on signs of depression, or asked a few basic screening questions at their one and only (and very brief) postpartum visit. But the reality is, most families aren’t given the information they need--or in a way that they can digest while adjusting to newborn life--to feel empowered to identify where their feelings of overwhelm cross into the territory of PMAD. 

PMAD isn’t just postpartum depression. You don’t need to be having feelings of depression to be suffering. PMAD includes:

  • Perinatal anxiety
  • Perinatal depression 
  • Perinatal OCD
  • Bipolar disorder
  • Post-traumatic stress disorder
  • Postpartum psychosis

PMAD only affects women or biological moms

You don’t need to have birthed a baby to experience PMAD. It can affect adoptive parents, same sex couples, and men. In fact, 1 in 10 dads experience PMAD, and 50% of men who have partners who develop PMAD will go on to develop depression themselves. 

You have to have had mental health concerns prior to pregnancy

It’s true that occurrence is higher in those with a personal or family history of depression, anxiety, or PMAD, but PMAD can affect people of all backgrounds. It does not discriminate. 

There is no single cause of PMAD, but occurrence tends to be higher in those with a history of premenstrual dysphoric disorder (PMDD), PMS, inadequate support, financial or marital stress, those with multiples or with infants in the NICU, those who have undergone fertility treatments or who had complications in pregnancy, those who have experienced a major recent life event, those who are sleep deprived (isn’t that all new parents?!), and those with certain hormonal imbalances (thyroid dysfunction, diabetes, or endocrine dysfunction).

My doctor screened me at my postpartum appointment so I must be fine

Mamas generally get one visit at 6 weeks postpartum, and it typically lasts less than 30 minutes. You’ll likely be asked to fill out a survey screening for certain symptoms of PMAD, but this is far from a foolproof way to identify PMAD. Furthermore, PMAD can manifest several months after birth, so even a mama feeling generally well at six weeks postpartum may still go on to develop  PMAD.

You can find screening tools online for postpartum anxiety and depression, but please don’t hesitate to reach out to your provider at any point for support. Symptoms vary by person and can come on and escalate quickly. You deserve the support you need, no matter when your symptoms arise.

Related Reading: Why ACOG and CDC Continue to Recommend Folic Acid Over Folate Despite Research Advancements

Why do nutrient deficiencies happen?

While you might think you eat a relatively balanced diet and that nutrient deficiencies couldn’t possibly be a source of your PMAD symptoms, the reality is, they are quite common in pregnant and postpartum women due to the incredibly high demands that pregnancy and breastfeeding place on your body. Some common causes of nutrient deficiencies in mamas include:

  • Entering pregnancy deficient: A deficiency prior to pregnancy generally only gets worse during and after pregnancy. This is why nutrient testing prior to conception is ideal, if accessible.
  • Depletion of stores: Baby uses mom’s nutrient stores during pregnancy and while nursing, so for many nutrients, if mama isn’t taking in enough for both herself and baby, she’ll generally find herself depleted.
  • Increased demands from lifestyle: Stress, caffeine, and postpartum recovery/healing increases nutrient demands beyond their already elevated levels.
  • Eating habits change: Even if mama was an impeccable eater prior to pregnancy, food aversions and nausea during pregnancy and stresses of postpartum life can throw a typically balanced diet off quite easily. 
  • Pregnancies in close succession: Some mamas may become pregnant again before addressing deficiencies from a prior pregnancy or breastfeeding journey, or before allowing their body to fully recover.

There is strong evidence to suggest that certain micronutrient deficiencies contribute to the development of PMAD, and it is well established that diet and supplementation during the perinatal time period can have an effect on PMAD occurrence and symptoms. 

Key nutrients to support mental health

Below are several key nutrients that have been specifically studied around their effects on PMAD.

Omega-3s (DHA + EPA)

Omega-3 fatty acids DHA and EPA are highly anti-inflammatory and have been shown to impact important neurotransmitters in the brain. In fact, research has shown that Omega-3 levels in both mama’s blood and her diet are associated with higher levels of depression and lower scores on PMAD screening tests. Research has also shown that sufficient Omega-3 levels (as well as a low Omega-6 to Omega-3 ratio) can help prevent postpartum depression. 

Since many mamas divert their Omega-3 stores to baby during and after pregnancy, deficiency is common. 

What you can do

Aim to eat at least 2 servings of fatty fish that are high in Omega-3s (like salmon or sardines) twice per week. If this is unattainable, the support of a high quality Omega-3 supplement is a smart and convenient way to help ensure that you and baby both get what you need. In fact, research has shown that mamas and mamas-to-be can benefit from up to 2 grams of EPA +DHA per day, so even if fatty fish is part of your weekly routine, a supplement can provide additional support.

You can also support yourself by avoiding or limiting processed foods high in inflammatory Omega-6 fatty acids, namely industrial seed oils like canola, sunflower, safflower, cottonseed, and grapeseed.

Vitamin D

    Vitamin D supports the body’s immune response and can help lower inflammation. A deficiency can also lower both estrogen and serotonin levels, which can affect mood. 

    Research has shown that low Vitamin D levels are associated with depressive symptoms in mamas, and researchers have found significant improvement in depressive symptoms with ongoing supplementation of Vitamin D.

    Vitamin D deficiency often starts in pregnancy when needs are high. Unfortunately, many prenatal vitamins don’t contain sufficient amounts, and food sources are limited. This results in many mamas entering the delicate postpartum phase already depleted. In fact, the European Journal of Obstetrics & Gynecology and Reproductive Biology acknowledges that “Vitamin D deficiency in mid-pregnancy may be a factor affecting the development of PPD.”

    What you can do

    Ideally, your provider will test your Vitamin D levels before and throughout pregnancy, but if not, you can do a simple at-home test to ensure your levels are within healthy ranges. 

    Vitamin D is limited in foods, but can be found in fatty fish, eggs, fish eggs (roe), and liver. Sunlight is also a great source of Vitamin D, but it can be a challenge to get sufficient sunlight to raise or even maintain the levels needed throughout pregnancy and postpartum. It can also be difficult to know how much sunlight you’re absorbing without frequent testing to check levels. Still, time outdoors and in the sun can certainly support Vitamin D levels, and often has benefits to your physical and mental health beyond just Vitamin D.

    The best way to ensure you are taking in sufficient Vitamin D on a daily basis is to take a high-quality prenatal vitamin with sufficient Vitamin D. Your prenatal may list on the supplement facts panel that it contains 100% of your daily value, but this does not mean it is enough to cover the needs of both you and baby. These daily values often reflect minimum amounts to avoid disease conditions, not optimal amounts to support physical and emotional health. Our Prenatal Multi Powder and Capsules contain a highly supportive dose of 4000 IU. 

    If your levels are already deficient, we recommend working with a practitioner to determine how much additional Vitamin D may help bring your levels back into a normal range (we share our general guidelines here). 

    Zinc

      Zinc supports the creation and functioning of neurotransmitters that impact brain function and mental health. Research has shown that low Zinc levels are linked to PMAD symptoms, and that supplementation can reduce depressive symptoms and feelings of anger and hostility.

      Ensuring adequate Zinc can also support the balance of Zinc and Copper, which can influence symptoms of PMAD. Copper levels nearly double in pregnancy, so Zinc can be especially supportive in offsetting this increase.

      Sufficient Zinc can be hard for mamas to obtain throughout pregnancy, particularly if you have meat aversions, follow a vegan or vegetarian diet, or have suffered with severe morning sickness or hyperemesis gravidarum.

      What you can do

      If you suspect deficiency, it’s wise to request a lab test in order to identify an appropriate level of intake to resolve your deficiency. Signs of deficiency include hair loss, loss of appetite, wounds that are slow to heal, weight loss, and reduced sense of taste and smell.

      To support optimal Zinc levels, make sure you’re getting sufficient amounts by staying on your prenatal and eating foods rich in Zinc. It can be found in red meat, dark meat poultry, oysters, clams, sunflower seeds, and beans. Like many foods, animal sources tend to be more rich in Zinc than plant sources. In addition to consuming enough Zinc in your diet, ensuring adequate stomach acid can help your body absorb Zinc properly. If you have a history of low stomach acid and have symptoms like heartburn, bloating after meals, and undigested food in your stools, work with a practitioner to support your stomach acid levels so that you can optimize your digestion of Zinc and other nutrients.

      Check your prenatal for Zinc content. Our Prenatal Multi Powder and Capsules contain a supportive dose of 25mg of well-absorbed Zinc Bisglycinate. Note that intake up to 40mg a day is generally considered safe, so even if you’re eating foods rich in Zinc on a daily basis, you can feel comfortable with additional supplementation at 25mg/day. For reference, a serving of beef (one of the richest sources of Zinc) contains 4-8mg of Zinc, so your intake would be within safe levels, even with a serving or two of beef each day. 

      Iron 

        Iron needs are elevated throughout pregnancy. While we know Iron is supportive of increased blood volume and thyroid health, research has also shown that it can support mood. Research has shown that postpartum depression, stress, and cognitive impairment may be related to Iron deficiency anemia. The good news is, increasing Iron intake in anemic women has been shown to improve symptoms of PMAD, and Iron supplementation in the postpartum period can decrease risk of PMAD in at-risk women.

        Sufficient Iron can be hard for mamas to obtain throughout pregnancy, particularly if you have meat aversions, follow a vegan or vegetarian diet, or have suffered with severe morning sickness or hyperemesis gravidarum. Anemia can also be triggered by large blood loss at delivery and heavy postpartum bleeding. Keep an eye out for symptoms, including fatigue, headaches, dizziness, irregular heartbeat, cold hands and feet, and an urge to chew on ice or sand.

        What you can do

        If possible, lab testing before, during, and after pregnancy can tell you if your levels are sufficient or if more Iron is needed, ideally before symptoms or complications set in. To increase your Iron levels, seek out Iron-rich foods like red meat, liver, oysters, dark meat poultry. Note that animal sources are better absorbed than plant sources. However, pairing iron from plants or animals with Vitamin C can help aid its absorption. You can also boost Iron intake by cooking your food in a cast iron pan. 

        If you choose to supplement, do so away from your prenatal vitamin (i.e. in the evening, if you take your multi in the morning), as Iron can interfere with the absorption of other nutrients, and choose a gentle but well-absorbed form like Iron Bisglycinate.

        Magnesium 

          During pregnancy, the baby and placenta absorb large amounts of Magnesium from the mother, and breastfeeding demands higher amounts of magnesium as well. Some research has hypothesized Magnesium deficiency to be one of the potential root causes of postpartum depression. 

          Unfortunately, our soil has become quite depleted, and so Magnesium levels in food have declined over the years. This makes obtaining adequate Magnesium from food difficult.

          What you can do

          Magnesium is not stored by the body, so daily intake is critical. Good food sources include pumpkin seeds, almonds, cashews, dark chocolate, and leafy greens. Magnesium is also well absorbed through the skin. Magnesium lotion or oil can be applied to the skin, and Epsom baths or foot soaks are both nourishing and relaxing.

          If you choose to supplement, know that the less well-absorbed forms of Magnesium Citrate and Oxide can have laxative effects. While some mamas appreciate this during times of constipation, too much can cause digestive discomfort so proceed with caution! Magnesium Glycinate is a gentle and well-absorbed form. Our Prenatal Multi powder contains 400mg of Magnesium Glycinate, and the capsules contain 200mg of Magnesium Glycinate.

          B vitamins

            B vitamins can help to manage inflammation and support memory, stress resilience, and the synthesis of important mood-related hormones like serotonin, dopamine, and noradrenaline. Depression has been linked to low levels of B vitamins, especially Vitamin B9.

            What you can do

            Like magnesium, B vitamins are not stored, so support a steady and sufficient supply by consuming B vitamins daily. Good food sources include meat, eggs, dairy products, legumes, seeds, nuts, dark leafy greens, and whole grains. Because the richest sources of B vitamins are animal products, vegan and vegetarian mamas are at higher risk of deficiency.

            Since B vitamins are eliminated daily, getting too little is generally more of a concern than too much. Even if you eat meat daily, supplementation with methylated B vitamins daily can help you meet your elevated needs during pregnancy and postpartum while also potentially providing some support against PMAD.

            Are YOU Okay?

            PMAD is common, but that doesn’t mean it shouldn’t be addressed. You and your baby deserve the best start together, and supporting yourself through proper nutrition as well as care from a licensed provider will benefit you both for years to come. Please don’t hesitate to seek support in whatever form is needed. 

            Disclaimer: This content is not intended to be a substitute for professional medical advice, diagnosis, or treatment. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a medical condition.

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            Steph Greunke, MS, RD, CPT, PMH-C

            Stephanie Greunke is a registered dietitian that specializes in prenatal/postnatal nutrition, behavioral psychology, and holds additional certifications in perinatal mental health and fitness. She's a key contributor and advisor to Needed as well as Needed’s Head of Practitioner Relationships. Steph is the owner of Postpartum Reset, an online postpartum nutrition course, and the co-host of "Doctor Mom" podcast.