I thought I would interject a post on the subject of the prenatal vitamin, spurred by a Twitter feed from a Canadian birthing magazine, called, natch, “Birthing.”  Since I have been browsing through the different birthing groups on Twitter, I’ve noticed this magazine seems to be very open to birthing options, avoiding unnecessary cesearean sections, promoting breastfeeding, etc., all topics in which I am interested.  So this is by no means a bash on their magazine.  But they wrote a short article about the prenatal vitamin (PNV), promoting the top three as they see it:  folic acid, calcium, and iron.   While clearly not meant to a scholarly article,  I think it represents mainstream information about the PNV which is, in my opinion, woefully inadequate.

Certainly, most people are aware of the need to take vitamins during pregnancy, and many of them who do not care to remember to take supplements when not pregnant, suddenly realize they are in the process of growing another human being and get on the PNV train.  Great!  Some vitamins are probably better than no vitamins, so it’s a good start (although Dr. Wiseman points out your average cheap vitamins often contain petroleum by-products, ground rocks and fillers).  However, there is growing concern that there are multiple areas of vitamin/mineral deficiencies that are affecting the non-pregnant female, which then becomes a bigger problem for the developing baby when she becomes pregnant.

Since I routinely test for vitamin and mineral deficiencies in women of childbearing age, I know how widespread such deficiencies really are.  In fact, the reason I do routine testing is because I was missing so much by not doing so.  Ob/Gyns are not really trained to practice preventative medicine, so these were lessons I learned in private practice.  But it wasn’t until I saw a Vitamin D level of 6 in a healthy 25 year old patient, that it began to hit home that I needed to be testing everybody (most experts recommend a Vitamin D level above 30, although optimal is more like 50, significantly deficient is less than 20).  Before I jump into Vitamin D again (admittedly one of my favorite subjects), I’ll start with the other elements mentioned in the article.

FOLIC ACID:  Most people have an awareness of the importance of this vitamin in pregnancy, even if they may not understand why.  Folic acid, also know as folate, is important for any developing cells so the rapid growth of a baby is dependent upon adequate levels of folate.  However, the biggest concern is in the prevention of neural tube defects like spina bifida and anencephaly.  What most people don’t know is, there is a very small window of time when folate supplementation can make a difference with these significant birth defects.  The neural tube (an embryonic structure that grows into the brain and spinal cord) is generally closed by the 52nd day of pregnancy…many women don’t even find out they are pregnant until they are past this point.  Intake of folic acid is actually more important in the pre-conception period, so that when the neural tube starts develping shortly after implantation of the embryo in the uterus, there are already high levels of folate, rather than deficiency, going in.   While different food products like flour have been fortified with folic acid, there is still far too many women who are deficient when they become pregnant.  Although the standard recommendation for women of child-bearing age is to have an intake of 400 mcg daily, this goal is clearly not being achieved.  Some experts believe that the problem is that there is not high enough levels of folate fortification to prevent even more NTDs than the drop that has already occurred.  As this article suggests, and as we are now seeing again with the ascendency of Vitamin D as death defying, cancer-fighting essential element and its acompanying naysayers, you will always see those scientists who oppose new recommendations without providing reasonable alternatives.  Though masking B12 deficiency by taking too much folate is what concerns most physicians, I have no problem recommending 1 mg of folate to my non-pregnant patients because I routinely test their Vitamin B12 levels.   And I also have no problem recommending higher than 1 mg intake of folate during pregnancy (previously only recommended to women with a previous NTD), for the same reason.

IRON:  You’re not going to get much argument from me about the importance of iron supplementation in pregnancy.  Many women become anemic in pregnancy as the developing baby will steal this essential nutrient from mom.  Women undergoing cesearean delivery in particular need to be closely monitored for iron-deficiency anemia, although you can easily lose a large amount of blood at a vaginal birth, so this advice is good for any pregnant woman, unless you have hemochromatosis.

CALCIUM:  Certainly the baby is going to take this important nutrient from mom to help with its own bone mineralization, so calcium intake is very important in pregnancy.  And there is some evidence that optimal calcium levels may decrease the risk for pre-eclampsia, although this is not a straight-forward association.   Most experts agree that pregnant woman need 1500 mg calcium, yet most prenatal vitamins contain only 200 to 300 mg, as cited in the Birthing article.  So unless a pregnant woman is getting a tremendous amount of calcium in her diet (or popping Tums for heartburn), she should take an additional calcium supplement.   However, without adequate Vitamin D, absorption of calcium is limited.  As I have alluded to, Vitamin D deficiency in child-bearing women is widespread.

VITAMIN D:  Readers of this blog will be familiar with my Vitamin D rants!  But it is frustrating to continue to see the evidence of how important this vitamin is, how easy it is to test for and supplement, and how it is still not getting the attention that it deserves.  The Birthing article put forth the obligatory recommendation of 400 IU of Vitamin D in the prenatal vitamin, which is just not enough, period.  I receive initial resistance in some of my patients for Vitamin D testing because they feel very secure in the 400 IU that their Caltrate contains.  When I educate them about how many people I see who are taking exactly what they are taking and are extremely Vitamin D deficient, most of them are surprised, and some of them are mad!  After all, they are doing everything they are supposed to be doing.  I sympathize.  It is hard to keep up with medical advances, and hard not to come across a food that is contaminated with Salmonella, pesticides or mercury, or feel the need to come in with a suitcase of supplements.  Here is a great summary article about the inadequacy of Vitamin D in prenatal vitamins and the multiple medical outcomes that are impacted by low Vitamin D in the woman, then pregnant woman, then baby.  Bottom line is, don’t take a chance, test every pregnant woman for Vitamin D.  There is no documented evidence that raising a woman’s Vitamin D level to a normal level during pregnancy has anything but advantages for the growing baby, but I would certainly only recommend natural Vitamin D3 rather than synthetic D2 be the preferred supplement.

VITAMIN B12:  Cell formation, DNA synthesis, and neurological development and function are all dependent upon Vitamin B12.  I hate to sound like a broken record, but just ask my office staff, we give B12 injections all day long and not just because everyone’s fatigued.  We test everyone and many are deficient.  The miniscule amount in prenatal vitamins may, and I emphasize MAY, be able to maintain someone with a good B12 level (greater than 400 pg/mL, but I would consider sufficiency greater than 600), but I would still think the easiest way to know, is not to guess!  Test!  This vitamin is too important for you and your baby’s neurological system to ignore.  Since meat and dairy products are the most common dietary sources for this vitamin, vegetarian and vegan moms must have their B12 levels monitored.

IODINE:  This particular article did not cite iodine at all in their prenatal recommendations which is a travesty.  The RDA for iodine for non-pregnant women in 150 micrograms a day, for a pregnant woman 220 micrograms a day, and 290 micrograms a day for a breastfeeding woman.  So why are there still prenatal vitamins manufactured without any iodine or inadequate levels?   Dr. Brownstein wants to know why too.  Iodine deficiency can cause hypothyroidism, miscarriage, stillbirth, preterm delivery, congenital abnormalties in the baby.  It can affect brain development, IQ, and behavior.  According to the International Council on for the Control of Iodine Deficiency Disorders (ICCIDD), iodine deficiency is the single most common preventable cause of mental retardation and brain damage in the world.  The only way to know for sure about iodine levels is to have the urinary iodine excretion test done, please read my iodine post for more on this.

OMEGA 3s:  Although there is no mention of Omega 3s in the Birthing article, we’ve seen the arrival of newer prenatal vitamins on the market that have added in essential fatty acids, typically DHA, as a result of research showing that omega 3 intake in pregnant moms can improve infant development and augments IQ.  It stands to reason that all the benefits to mom in terms of reducing inflammation in the body, improving lipid profiles, and augmenting the immune system, will translate into higher levels in Omega 3s in baby, which has been documented in the literature.  The main concern, of course, is purity of the omega 3 source, since we don’t want to trade one problem for another, namely mercury toxicity.  So the pregnant woman in particular must be sure that she is taking a highly purified toxin-free form of fish oil or choose vegetarian source, flaxseed, although you also have to be careful with this one because it goes rancid as soon as it is exposed to light.  Bottom line:  spend a little more, get small, fresh quantities and use them quickly.  My office staff laughs when I give my “Your $3.95 jumbo jar of fish oil from Wal-Mart is not going to cut it!” speech.  Carlson labs has very purified fish oil, including one especially for pregnancy, called Mother’s DHA.

Overall, relying  on just one prenatal vitamin to supply all your needs in pregnancy is not adequate, especially if you are starting out deficient or don’t have a good diet.  I am currently pregnant and even though I take a whole-food based prenatal vitamin from Innate Response, I take additional folate, Vitamin D, iodine, Vitamin B12 and chelated iron.  I have my blood work monitored to know what my levels are, especially vitamin D, since these have been low in the past.  In addition, I try to eat as much organic whole food as possible.  Then once the baby’s born and I’m breastfeeding, it’s even more important that I keep my vitamins on board to give my baby a great start!