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Bonus: Jackie Eberstein – Nutrition Before, During, and After Pregnancy

Jonathan: Hi! Everyone Jonathan Bailor back with another bonus Smarter Science of Slim podcast. Very, very excited about today’s show but also I want to give folks a heads up that we’re going to talk about some pretty serious topics, the topics that need to be talked about. We’ll be talking about those topics with one of my favorite people in the world, someone who has been in this field for many, many, many decades. I guess I shouldn’t say many, too many times, she is …

Jackie: Now please Jonathan four times is enough…

Jonathan: She is a registered nurse and a most well known for her foundational work with Dr. Robert Atkins back from the very beginning. She was the Director of Medical Education at the Atkins Center for Complimentary Medicine in New York City and she is really been working on the forefront of controlled carbohydrate nutrition, since its inception. She is now a consultant working with the Veronica Atkins’ personal foundation for furthering education at the Atkins lifestyle and on the legacy of Dr. Atkins. Today Jacqueline Eberstein is with us to share some amazing research that is really not talked about regarding gestational health and what we can do to help prevent and control diabetes and these diseases of carbohydrate intolerance. Jackie welcome to the show.

Jackie: Hi! Jonathan thanks again for having me.

Jonathan: It’s absolutely my pleasure Jackie and I’m so excited to talk about this research because it is so important and it is not easy to talk about, is it?

Jackie: Well, it isn’t because we’re going to talk about how being overly fat, both in men and women by the way, before making babies impacts that baby and impacts that baby for the rest of their lives. It’s a touchy subject when you talk about women gaining weight in pregnancy because it seems almost like you’re picking on them and pregnancy is difficult enough without talking about what they’re eating and how fat they’re getting. I want to clarify that’s not the reason why I want to talk about this. I think it’s an incredible serious topic and doesn’t get talked about for many reasons. One of them maybe the issue that it’s not politically correct but I think more and more people, both men and women, who are at the age where they’re making babies have to have some understanding of the long term impact.

With the issues of obesity that we have now, more and more men and women are overweight or obese and they’re being overweight and obese younger than ever before and also they are bigger than ever before. It really isn’t just about cosmetics, it’s about so many things and it’s about the legacy they’re going to pass on to their offspring.

It’s also going to be about can we afford the cost of creating another generation who are going to be very sick, very early in life and potentially disabled earlier in life. I’ve been interested in this for now about three years and been collecting data about this hoping at some point I could talk about it but I just don’t think it’s discussed or people don’t even know. I think a lot of it is just absolute ignorance and doctors don’t really talk too much about it because I don’t think they actually know what to do about it.

That’s kind of what I would like to present today to give everybody out in your audience whether you’re a mom who’s raising kids, whether you’re a potential mom or dad, whether you’re thinking about having other children, whether you’re grandmother and you are concerned about your family and they are not eating well and they’re gaining weight and the impact that may have. I’m just hoping if you get some people thinking about the seriousness of it, we can start to really do real prevention.

Jonathan: Jackie I so appreciate that and I appreciate the courage it takes to bring up topics like this and I would encourage listeners, this is not an easy subject to cover as Jackie has already talked about. I would urge you as Jackie is alluded to; this is not about making anyone feel guilty, it’s not about making anyone feel bad. We at Smarter Science of Slim podcast, we’re going to present to you with the science, we’re going to present you with facts, we’re going to give you the power to then make the decision that best work for you and for your family. Knowledge is power, I don’t want to be trite so Jackie is just here to empower us, let’s see it that way. With that Jackie, let’s rock and roll let’s dig in to the data.

Jackie: Okay, what I want to do is, I’m going to be presenting some statistics that I think most of us have been completely unaware of and we have to start taking seriously. Then I’m going to talk some about studies and then talk some about the rates of C-section in the country, the complications, the risks to mom and baby, how we can try to lower that number. Also talk about gestational diabetes which is on the rise and we know that any kind of diabetes is going to respond much better to controlling carbohydrates, so that’s really one of the solutions that we can present. Then talk a little about breast feeding and the healthy foods and nutrients we need when moms are pregnant. It isn’t about quantity of food; it’s about the quality of food so that you can construct a healthy baby.

My topic, the title is, “Making a healthy baby: what future moms and dads need to know”. We know that we’ve got this overweight and obesity issue in the country but it becomes much more problematic when we realize that almost 50% of pregnancies in the United States are unintended. If you are thinking about getting pregnant you’re more likely to think about being healthier before, but if pregnancies are unintended in all likelihood, a lot of people making babies aren’t really healthy even though they may not acutely sick, they’re not healthy. They don’t have healthy genes if they’re overly fat and they are going to be passing on those unhealthy genes to their children.

The health of a child is really going to be determined by the health of the mom and dad at least six months before conception happens. What I’m really saying is, is that those men and women out there who are at the age that they’re able to make babies need to start to pay attention to the amount of weight that they’re carrying because that’s going to impact a pregnancy. There was a recent study done at Duke – and most of the studies are done about the impact of obesity and pregnancy on moms but it’s not that the dad doesn’t have any responsibility, he really does. There was one study recently presented at Duke, where they examined the genes from obese dads and found out, that the unhealthy functioning of those genes can impact that child’s cancer risks later in the child’s life. I don’t think that something anyone would ever really think about, so dad plays a role here.

There’s a study in Australia now, this one is done on mice and has not yet been done on people, but it would stand the reason that it’s possible there can be a similar outcome that the sperm of overweight dads carry molecular signals that can transmit the molecular signals of obesity to their offspring and unfortunately it seems to impact girls more the boys. The girls do have a more difficult time with weight; women do, because of a lot of things that are different about their physiology including their hormones. You really need dad’s to lose some weight before you make babies – that’s basically the message for the dads out there.

Now, about obese moms, there’s been studies done on them and they find that the genes of the fetus from a mom who is carrying too much weight, express genes differently particularly related to brain development and that’s already been shown in the second trimester of a pregnancy as compared to the gene functioning of women who are the normal healthy weight in the second trimester. That then potentially, is thought that there may be higher risk of autism and there’s a lot going on there discussion about obesity, gestational diabetes and autism and also appetite disregulation in that child. We’re really programming these kids from actually the first month of conception, because that’s when a lot of the neurologic programming is happening in a fetus and many times women don’t even know they are pregnant at that point.

There’s also a host of birth defects that can happen when a mom is obese and a number of them are neurological, because it happens so early in development to the brain structure. One common one is spina bifida, where the spine doesn’t close properly and depending upon the degree of abnormality a child could have lifelong disabilities because of that. It’s one of the reasons why folic acid is added to certain foods because low levels of folic acid not only in a pregnant mom but in a pre-pregnant mom, can predispose for the development of spina bifida in the baby, also other neural tube defects.

The neural tube is, is the beginning of the development of the nervous system in a very young fetus. Hydrocephalic that’s when the brain head against to swell because the cerebral spinal fluid can’t be drained properly and of course kidney and heart problems are much more common in kids born to obese moms so are cleft palate and cleft lip. The thinking is, is that a number of these defects maybe caused by poor diet, as we mentioned, which could lead to obese an mom, diabetes because of the abnormalities of high blood sugar circulating in a developing fetus and high insulin levels and also because you’re missing nutrients. As I’ve mentioned the folic acid that could lead to spina bifida. Those are just some of the issues that just obesity can tend to present to mom and baby
Jonathan: And Jackie, the thing that again is this like a wave of, “Oh my God” that’s not the intent. I think what is exciting – maybe is the wrong word – is to think about again if our motivation is just some arbitrary societal, like look this way, fit in this size, have this number on the scale, that’s not very noble or motivating thing but if we’re here to empower generations that really keeps us going. Jackie, I so appreciate this so let’s keep going.

Jackie: Okay, the other point I want to throw out there is, as we already know that generation of kids who are here now are developing lifestyle related diseases very young. My point in presenting all of these is really, there are things we can do to decrease the odds of creating a second generation this way and the impact that we’ll have on our inability to really deliver health care to sick people in the future is what also motivates me to have this kind of a discussion. I think that a lot of us are unaware, there’s this idea the United States has its most advanced health care system. We certainly have a lot of advanced health care technology; clearly our delivery system doesn’t work for everyone.

I don’t think most people realize where we fit in the world with some statistics here but in the United States, we are 50th in maternal mortality rates. There are 49 other countries where moms die less often and in smaller numbers than we do during the process of pregnancy, delivery and early postpartum. I think that’s frightening, I didn’t know that till we really start to look into it and more than half of those maternal deaths can be prevented because of a lot of them are lifestyle related.

The other issue we have of course is that 20 percent of women between the ages of 20 and 44 have pre-diabetes. Now Jonathan you understand that pre-diabetes is basically as serious as diabetes and needs to be treated, yet we have all these young women who probably are unaware that, that’s what they have. One of the tipoffs is also high triglycerides and we talked about triglycerides that is being a risk for carbohydrate intolerance, a symptom of carbohydrate intolerance but those women who have high triglycerides are also most likely to get gestational diabetes and also most likely to get a complication of obesity diabetes called preeclampsia, which we can talk about but we’ve got already a young population that’s ill and those are the people we want to talk to because they don’t have to be ill.

Jonathan: Jackie it’s certainly. It is a critical time because when we see, there’s a researcher by the name of, I forget her freaking name, she’s at the University of Colorado and she has a paper on this topic which talks about how when you have one generation and it’s struggling with overweight and diabetes that is what one thing but if then the existence of that generation predisposes their offspring to have the same problem. If you thought it was hard to avoid obesity and diabetes when you didn’t have a genetic predisposition, then it becomes even a harder, right? So we got to avoid that vicious cycle.

Jackie: It’s going to become even harder if both parents, when the baby is conceived are sending unhealthy genetic messages to that baby. I am convinced that’s why we have so many young kids now, teenagers and young people now who are ill because their parents were the beginning of that group who because of the health messages and diet messages we’ve been given started to eat differently. We’ve already seen one generation being prematurely made sick because of that and we need to try to prevent the next one from having it happened.

Let me get on to the subject, gestational diabetes because that’s on the rise of course because obesity is one of the reasons why a woman can get diabetes during pregnancy. If a number of women are already pre-diabetic before they get pregnant, that’s one of the reasons why we see these escalating rates. One thing that happens when a woman becomes pregnant is that she develops more insulin resistance, that’s just natural because of the significant hormone changes and changes that occur in her body. Somewhere around the mid-stage of pregnancy is when women are tested to see if they’re developing gestational diabetes. It used to be the numbers of four or five percent of every pregnancy led to that but now, we are seeing numbers as high as 18 percent.

The complication you have there is, instead of the diabetes going away once baby is born which is what it used to do, that’s not happening anymore. Up to ten percent of women who get gestational diabetes remained diabetic and of those women who aren’t remaining diabetic, significant number of them in the next few years will become diabetic. You’re talking about women who could be in their late thirties or early forties and they already have Type II diabetes, so it’s a really serious issue. Another reason why that happens is because women often get pregnant too soon. The recommendation is you should wait two years between pregnancy so the body can recover and you can lose your pre-pregnant weight. Many times women don’t lose their pre-pregnant weight or carrying more weight and then they’re pregnant again.

I can remember working at the Atkins Center and taking pregnancy histories on women and they would literally be sitting in my chair crying, saying, I’m sitting here now – and they may be in their forties, saying “I’m heavier now than when I was when I went to the hospital to deliver my babies” because they never had the opportunity or were unable for whatever reason to normalize their weight in between babies. That’s going to increase significant risks for each pregnancy. What happens is, from a health care delivery system cost is that gestational diabetes has a 34 percent increase in cost for the moms and the baby’s care, because the baby is at risk in the uterus of a woman with gestational diabetes and then the first days after the baby is born as the baby’s own pancreas tries to adjust to changes in its insulin and blood sugar, so these babies have to be watched much more closely.

And because of gestational diabetes and obesity, one of the things that often happen is we do C-section in this country. A third of all births in the United States are by C-section. It shouldn’t be any more than ten percent of birth, we’re doing way too many and way too many for lot of reasons and there’s a risk to mom and baby. Normal delivery, yes it’s very painful and it has its risks but most people don’t realize that C-section can be more risk to mom and baby. One of the reasons is it’s a major operation and women can get blood clots, they can get infection, there can be damage to the bladder, a bowel during the surgery and when you have one C-section many hospitals are unwilling to then allow that woman to deliver normally the next time. A woman may wind up with three or four C-sections in her lifetime.

There’s also risk to the baby with a C-section. One of the reasons though why we do so many is, our babies are too big, it’s called macrosomia. As mom’s getting too big because of the disturbance of her metabolism and her poor diet, perhaps during pregnancy, the baby is getting bigger and if the mom gets diabetes, increased insulin affects the baby, it’s a fat-making hormone, the blood sugar affects the baby and babies gets bigger and they can’t fit or the mom can suffer significant injuries in trying to deliver a baby that’s too big and can the baby a lot of times the baby can even get dislocation in its shoulder trying to fit through the birth canal to be born. Then there’s a risk, as I mentioned, preeclampsia and significant increase cost.

The other interesting thing with gestational diabetes is that can be a risk for babies to be born to soon. Normal gestation is considered 38 to 40 weeks, it’s really closer to 40, but if a baby is born before 37 weeks, then you can have a baby who’s not ready to be born, who is going to require significant additional care. In the United States, we have higher rates of preterm birth than 130 other countries. Again, we look at our health care system and wonder what are we doing wrong here and part of that we’re doing wrong is we’re just not really all taking care of ourselves or each other in order to make healthier babies. The other thing that can happen to babies when they grow up is if you’d had a preterm delivery, you are already going to be carrying around lower insulin sensitivity which may very well create a real problem later in that adult’s life.

What happens around conception and pregnancy and delivery has lifelong implications and that’s really the point I’m trying to make. C-section babies have more asthma, they have more obesity, they have more diabetes, the connection to some of that may be because they don’t go through the mom’s birth canal, the gastrointestinal track which is where most of our immune function happens isn’t matured in the right way. They don’t get inoculated by mother’s bacteria in the gut so that the baby’s immune system can begin to start to grow and function properly.

In a C-section, you’re lifted out of your mom’s uterus and you have all but maturation of the GI organisms that has to happen and that baby is behind schedule. In we’re just starting to look at the impact on disease and health with the balance of organisms in the gut. There’s so much more, I think the next 10, 12, 15 years we’re going to learn but that’s already suspect that some of these issues in C-Sections may be a problem for the baby.

Obese moms are likely to have their baby die in the first month or have a stillborn child. Those are serious consequences and I’ve never know anybody personally with that but obviously the statistics are there and we have to take them seriously. We’re also finding as even if a mom is in normal eating, well isn’t gaining a normal weight but a normal weight at the beginning of pregnancy that 52 percent of women gain too much weight during pregnancy. There’s not this idea of how much we should gain, you’re “eating for two” supposedly, well you’re really not needing to eat very much more for two. It’s more the nutrients, the protein, the fatty acids, the vitamins and minerals that the baby needs to be constructed properly and to be healthy when they’re born. It isn’t the quantity of food or the poor quality of food that the mom needs to eat.

I think a lot of that can lead to cravings. If moms were eating a lot of carbs before I think they’re likely to crave a lot during a pregnancy and have a lot harder time in managing their weight. There are new guidelines because there’s now so many women with so many different levels of obesity that there’s new weight guidelines about how much a woman should gain. A woman of normal weight should not gain more than 25 to 35 pounds. An overweight woman, that’s just a woman who’s got a Body Mass Index that’s just slightly above normal, shouldn’t gain more than 15 to 25 pounds spread out through the whole 40 weeks of gestation and an obese woman does not need to gain more than 11 to 20 pounds. These are fairly new numbers and I don’t know how much people are really aware of those numbers. Part of the difficulty with prenatal care with doctors is they don’t have a lot of time to really teach women how to do this and I think that’s part of the difficulties is women just don’t have the information they need.

Jonathan: Jackie I want to pause really quick.

Jackie: Yes.

Jonathan: Do you have any way to close other programs on your computer, our connection is slowing down.

Jackie: Oh yes of course. I hope I don’t disconnect you. No, I guess I won’t will I.
Jonathan: Of course I’ll edit this part out so don’t worry.

Jackie: Is that better? Okay. Is this better? Can you tell? I’m pretty much out of what looks like everything.

Jonathan: Okay. For some reason…

Jackie: I didn’t have much open…

Jonathan: Okay. No, no problem. Let’s just keeping rocking and rolling here. We are kind of petering out on our connection speed. I don’t know what’s going on but let’s wrap up with some suggestions on what can be done, obviously, to avoid these things and we’ll go from there is that’s cool.

Jackie: Okay. I think one the important things you can do, if I’ve already said, is start to think about your health even before making babies and get your weight down. One of the important things women can do if you’ve already had a baby and you’ve had some issues and your concerned about the baby having been too big is that breastfeeding provides so many benefits. The recommendation now it that the baby should be exclusively breastfeed for the first six months and then up to a year at least while your adding in between six months and a year and while your adding in other foods. The reason is, is because there are different growth patterns between babies formula fed and babies breastfed. Usually baby’s formula eat too much, they tend to grow more, they tend to grown faster. Now that’s not a good thing.

Babies who are breastfed have less exposure to insulin-like growth factor and to insulin so it slows their rate of growth even when they start eating solid food to a normal rate. Formula fed babies often have increased numbers of fat cells which means they’re most likely to carry more weight. The longer breastfeeding is continued, three to six months, these kids tend to have lower, healthier weights than babies who are formula fed. One of the important things is that, and there’s been some discussion about breastfeeding being much healthier for brain development and there is a recent research that said it is. The fatty acids in breast milk, the cholesterol in break milk actually can promote better growth of the white matter of the brain. These kids can have somewhat higher IQs; they can have better language skills. It’s important that we get them started, maybe even during your pregnancy you weren’t healthy as you wanted to be, breastfeeding can make a significant difference.

It also protects babies from allergies and asthma, stomach infections, eczema, ear infections so that these kids are likely to be healthier and potentially need less exposure to antibiotics when they’re babies. There is less ADHD in kids who are breastfed, there’s less obesity, less diabetes. They’re gut environment is much different and healthier than in babies who are formula feed. Unfortunately, the marketing of formula companies have wound up making a lot of mothers, particularly minority mothers thinking that the formulas are healthier than breast milk and you couldn’t be any further from the truth. Breastfeeding moms get an advantage, is that early breastfeeding, right after delivery helps moms recover from delivery and cut down the bleeding from the uterus after birth. They also have helped lose some of their pregnancy weight faster and there is less risk of pre-menopausal, breast cancer osteoporosis and ovarian cancer in moms who breastfed so there are benefits there and it’s less expensive.

Important foods, I’ll go very quickly through this and foods are normal foods that we should be eating and they also have to be low carbs foods. We need choline for brain development, makes kids be less stressed. If when they were in the uterus there mom got adequate sources of choline which is a B-complex factor. Meat, eggs, broccoli are a good sources of choline. They also play a role in decreasing the risk of schizophrenia by getting adequate choline. Folic acid, we already talked about, good sources of folic acid are leafy greens, avocados, nuts, seeds and eggs prevents birth defects, lowers autism and perhaps schizophrenia risk. Vitamin C before… I’m sorry Jonathan I have to cough can you wipe this out?

Jonathan: Oh yes, no problem.

Jackie: Okay. I’m almost done. There’s a research that was done showing that low levels of vitamin D in mom before pregnancy and during pregnancy can actually decrease brain development in her child, which potentially can mean they have a poorer memory in these kids. The interesting and sad part is, is that supplementation to these children of vitamin C after birth didn’t help improve the problem. It’s important to know that smoking can really cause Vitamin C deficiency in a woman who’s pregnant, so it’s important women not smoke.

Adequate vitamin D of course has been talked about for so many things you can get vitamin D from fish, egg yolks, cheese. Moms who breastfed don’t have adequate vitamin D generally, most women don’t, you really do need to see your doctor, get a blood level done and get supplementation. Iron, you can get iron from eggs, red meat, fish, pumpkin seeds. Magnesium is very important, nuts and seeds, spinach, sweet potatoes – these are all healthy, whole low carb foods. Calcium is important and obviously to help build skeleton of the baby, along with magnesium and Vitamin D. Leafy green, cheese, salmon and the omega-three fatty acids for better brain development, healthier brain development. Salmon, nuts and seeds are foods that moms can concentrate on and there are also foods that will help to control their weight gain which is what you want to do in pregnancy and also not stress blood sugar and insulin. In a quick, what half hour? – Sorry Jonathan we never talk, that’s what I can tell you.

Jonathan: Jackie and again I want to salute you for sharing this because of the key thing for us right is that we have proper information. For example, I would imagine mothers in the early 20th century were just told, yes it’s fine to smoke, during, before and during pregnancy it’s not a big deal, right? Everyone smokds and being around people who smoked, it’s fine. But when we learned the actual science and that made it to the surface and that cut through the marketing hype and in it cut through the corporate deception – for a lack of better terms – we were properly informed and we could decide accordingly. I think what you’re sharing with us, is just showing that just because it’s sold in a grocery store and just because there isn’t a restriction on the age of people who can buy it, doesn’t mean that it can’t have dramatic, dramatic – on the level of smoking, dramatic effects on our health and the health of generations to come. Is that fair?

Jackie: I think it’s absolutely correct. I think that one of the reasons why I think they’re starting to be research looking at this, is because of the explosion of neurologic issues we now have in the last 20 years, ADD, ADHD, autism, schizophrenia, Alzheimer’s. Where did some of this come from? Why are we suddenly starting to see all of this? I think that there people out there who were looking at, it can start as early as the first month of pregnancy, perhaps the tendency for it. That’s the reason why I think this is so important because so much of it is fixable.

Jonathan: And so much of it is in our hands which is great.

Jackie: Absolutely.

Jonathan: You don’t need some pill, you don’t need some magic formula, you don’t need some personal counselor, these are just decisions and you’re not also prescribing some sort of crazy way of eating. You’re just saying, focus on these delicious whole natural nutrient-rich actual foods and that’s delicious, so that’s good.
Jackie: Which is frankly what moms used to eat.

Jonathan: Exactly.

Jackie: When I was in nursing school, you didn’t see what we see now in the delivery room, I remember seeing one woman with gestational diabetes and that’s because she had didn’t any health care. Her baby was stillborn by the way, but you just don’t see the rates of what we are seeing now and what’s changed is our diet, that’s what changed.

Jonathan: Well Jackie, I so appreciate you, you sharing this information with us, obviously a very important subject. Folks if you want to learn more about this please do check out Jackie’s work. You’ll find her on the web as Jacqueline Eberstein at controlcarb.com and Jackie, is there a place or a resource that covers some of the information we talked about today?

Jackie: Well, actually not one place. One of the things that I am going to do is I plan on writing. I want to write a big article about family health and about this issue and put it on my site so that’s something I hope, will be there, maybe in the next two months.

Jonathan: Beautiful. We’ll actually probably be up by the time this show airs, so good news listeners.

Jackie: Yes, I collected this information from many different places over the last three years so I’m not aware of any one site who can really make it concise and hopefully understandable for people.

Jonathan: Well, hopefully your article will do that Jackie and that folks will be findable at controlcarb.com. Again Jackie, thank you so much for joining us today and sharing this critical information with us.

Jackie: Well, thanks Jonathan.

Jonathan: Listeners, I hope you enjoyed today’s show as much as I did. Although some of it may have been tough to hear, right? We just got to get the facts out there and to empower ourselves to make the smartest decisions possible, so thank you so much for joining us and remember this week and every week after, eat smarter, exercise smarter and live better. Chat with you soon.

This week we have the pleasure of hearing from Jackie Eberstein. In her own words:

Nourished: A Cookbook for Health, Weight Loss, and Metabolic Balance

Jacqueline Eberstein, R.N. began working with Dr. Robert Atkins in 1974. Her previous experience included stints in intensive care and recovery room nursing.

As Director of  Medical Education at The Atkins Center for Complementary Medicine in New York City, she was responsible for the education of medical staff on the principles and protocols of the Atkins Lifestyle. Additionally, she spent many years as a full time practitioner utilizing complementary medicine approaches as practiced by Dr. Robert Atkins. She designed and ran The Atkins Center’s Modified Diet Program and Atkins Low Carb cruises

She contributed to a number of Dr. Atkins’ books, newsletters, Atkins: A Passion for Healthy Living magazine and appeared regularly as a guest and host on “Your Health Choices”, Dr. Atkins syndicated radio program.

After closing The Atkins Center in October 2003, she became Director of Nutrition Information at Atkins Health and Medical Information Services for Atkins Nutritionals, Inc. In that capacity she co-authored Atkins Diabetes Revolution published in 2004 by Harper Collins (for review click here).

She is presently a consultant working with Veronica Atkins’ personal foundation furthering education in the Atkins Lifestyle and the legacy of Dr.Atkins.

She is a regular contributor to Diabetes Health magazine.

Because of her extensive experience using the Atkins Lifestyle she is one of the foremost authorities on the subject.”