Supplementing a healthy pregnancy

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Supplementing for a healthy pregnancy

It is now relatively common-place for a woman who has discovered she is pregnant to seek out advice on the use of vitamins and other complementary medicines. This practice is largely due to the widespread understanding that folic acid is an important factor in the prevention of neural tube defects. For those who who plan their pregnancy well in advance, they may begin their pre-conception supplementation regime months ahead of time - this area of pre-conception is a key health service that integrative medicine professionals offer over standard medical practitioners. 

We’re often posed the question: “Is supplementation necessary - shouldn't adequate levels of nutrients be available from the diet alone?”. 

The answer to that is a complex one. In short, it’s incredibly uncommon to find someone who meets, let alone exceeds daily nutritional intakes of fresh vegetables, moderate amounts of fruit, good quality protein - in freshly prepared meals. It’s also rare to meet anyone, who isn't under the mental and physical demands of stress and whom isn't constant being exposed to a myriad of toxins and chemicals that are also placing demands on the body’s resources. Getting enough fresh air, sunshine, fresh water (not hydration robbing soft drinks, coffee and tea) as well as having a diet low in sugary, packaged and fast-food meals is another consideration in modern diets and lifestyles. Modern agricultural practices also have a role in the lack of available nutrients and antioxidants from the foods we eat. 

Modern life means supplementation has become a necessary “insurance” in the quest for a healthy pregnancy and there are now a multitude of supplements available to pregnant women, so how do we decide which supplements are the most ideal? How can we move beyond the pretty labels and fancy advertising - which can often be misleading [1] and ensure the regimes we select meet the demands of a healthful pregnancy? Certain nutrients are vitally important to look for…

How necessary is a multi vitamin?

Over the years, numerous studies have linked the use of multivitamins, taken before conception and whilst pregnant, to healthier pregnancy outcomes. Prenatal multivitamin supplementation is thought to not only provide protection against the likelihood of congenital abnormalities, such as neural tube defects [2] but studies have also shown that the use of a prenatal multivitamin formula (when compared to only using a folic acid-iron combination) can also significantly lower the risk of low birth-weight babies.[3]

Look for a prenatal multivitamin that contains essential nutrients for foetal and maternal health including: B vitamins, choline, iodine, vitamin D3, coenzyme Q10 and iron. As a minimum, a multivitamin should meet the ’Recommended Dietary Intakes’ (RDIs) or ‘Allowances’, which are the amounts of specific nutrients required on average on a daily basis for sustenance or avoidance of deficiency states [4] however, bear in mind, these are not optimal, “health promoting” amounts, purely a guide to the minimum needed to mitigate disease.

Example Recommended Daily Intakes (RDI) in Pregnancy*: [4]

NUTRIENT

Women

Pregnancy

Lactation

Thiamin (B1) 

mg/day

1.1

1.4

1.4

Riboflavin (B2)

 mg/day

1.1

1.1

1.6

Niacin (B3) 

mg/day

1.4

1.8

1.7

Pantothenic Acid (B5) mg/day

4.0 

(A.I)*

5.0

(A.I)*

6.0 

(A.I)*

Vitamin B6 

mg/day

1.5

1.9

2.0

Vitamin B12 

mcg/day

2.4

2.6

2.8

Folate 

mcg/day

400

600

500

Biotin 

mcg/day

25

(A.I)*

30

(A.I)*

35

(A.I)*

 

 

 

 

*Adequate Intake (AI) is used when an RDI cannot be determined. This is the average daily nutrient intake level based on observed or experimentally-determined approximations or estimates of nutrient intake by a group (or groups) of apparently healthy people that are assumed to be adequate. 

The importance of Iron

The nutritional demands for iron, a mineral necessary for the normal growth and development of the foetus and its brain, increases substantially during pregnancy. With increases in blood volume necessary for the growing baby, the demands for iron reach their highest in the second and third trimesters. 

Supplemental or dietary vitamin C improves the absorption of both supplemental and dietary iron. Both vitamin C and iron must be present together in the intestine for iron absorption to occur. In fact, vitamin B6, folic acid and vitamin B12 are also required for healthy red blood cell metabolism and formation.

Supplementing with iron can bring with it the potential for gastrointestinal upset and constipation. Therefore it’s a good idea to seek advice on what type of iron to take. Ferrous (iron) fumarate, gluconate and amino acid chelate forms are well-absorbed and typically better tolerated and less constipating than ferrous sulfate.[5,6]

CAVEAT: It is essential all pregnant women have a blood test to determine if iron supplementation is required. Unnecessary iron supplementation during pregnancy may cause undesired birth outcomes such as small-for-gestational-age babies.[7]

Iodine: Not to be underestimated

Iodine may not get the same level of spotlight as folate when it comes to pregnancy health, though it is equally as important. Deficiency of Iodine is now so common and such a public health concern, that in 2009 new guidelines from Food Standards Australia and New Zealand (FSANZ) emerged that both folate and iodine fortification in commercial breads be made mandatory. They estimated that by including iodine into commercially available bread, they could reduce the relative rate of iodine deficiency from 43% down to 5% of the population.[8,9]

Iodine, essential for the normal growth and development of the foetus and baby, is commonly deficient in pregnancy.[10,11] It is critically important for growth and healthy development of the baby’s brain and central nervous system. It contributes to the healthy maturation of the baby’s eyesight and hearing. If left untreated, an iodine deficiency can lead to neurological defects, including reductions in auditory and cognitive function, and can cause the thyroid to become underactive, in both mother and baby.[12]

Evidence suggests, iodine requirements increase by 50% or more during pregnancy. Iodine supplementation for pregnant women is recommended by the World Health Organisation at 250mcg per day.[12]

VITAMIN D DEFICIENCY

Despite Australia’s sunny climate, it is estimated that maternal vitamin D deficiency is present in 40-80% of pregnant women.[13] Inadequate vitamin D nutrition during perinatal life may establish a poor foundation that may produce long-term issues to a person’s health.[14]

In pregnancy, vitamin D deficiency can lead to low birth-weight babies [15] and is linked to reduced bone mineral accrual in offspring.[16] This can affect skeletal growth and tooth mineralisation. 

Vitamin D can obtained from sun exposure; when ultraviolet B light produces a reaction on the skin. Synthesis is easily impaired by sunscreens, make up, moisturisers, tanners - and obviously, clothing. Very little is available naturally in food, except in oily fish such as cod liver oil, or good quality butter from pasture fed cattle. 

Vitamin D deficiency and its effects on children’s bones are emerging as a major paediatric health issue in Australia and New Zealand due to proficient sun protection and the growth of indoor work and lifestyle activities.[17] A steady increase of vitamin D deficiency was reported at The Children’s Hospital at Westmead, NSW in 2006 following an 11 year study.[18] The biochemical and clinical signs of vitamin D deficiency can be prevented with adequate sun exposure, and vitamin D supplementation.

OMEGA 3 FATTY ACIDS

A large body of research supports the importance of taking omega-3 fatty acids, eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA), during pregnancy and breastfeeding. 

Found predominantly in deep-sea cold-water fish, flaxseeds and dark green vegetables, omega-3 fatty acids must be consumed either through the diet or from taking supplements because the body is unable to synthesise them.

The rapidly developing foetus has a high demand for fatty acids, especially DHA, which is critical for normal development of the foetal brain, nervous system and eyes. The baby’s supply of DHA is met exclusively from maternal intake. The metabolic demand for DHA increases during pregnancy, progressively depleting the maternal supply from 28 weeks to term.

A higher DHA supply to the foetus, during pregnancy and after birth, has been associated with benefits to visual acuity, cognitive function and maturity of sleep patterns. Follow-up studies have shown that infants of mothers who supplemented with DHA had higher mental processing scores, psychomotor development and hand-eye coordination at four years of age.[19]

It is believed that a foetus accumulates DHA at an average rate of 67mg per day. This, compared to the average daily intake of 15mg of DHA by most Australian mothers, leaves a wide gap.[20] So crucial is DHA for foetal development, that if mothers consume less than a developing foetus needs, the mother’s body preferentially diverts DHA from her own stores to supply the foetus. Evidence also suggests that maintaining maternal DHA reserves during pregnancy supports healthy mood.[21]

What about Vegetarians?

Omega-3 triglycerides cannot be made by the body and must be consumed through the diet to obtain all their benefits. In the past, this has been a challenge for vegetarians as the highest dietary sources are typically of animal origin.

Now there is a vegetarian source of DHA available for supplementation during pregnancy, suitable for vegans and for women whose religious beliefs prevent them from taking fish oils as a source of omega-3 and essential fatty acids.

Traditionally DHA is sourced from fish oil; it can now also be sourced from Schizochytrium sp., a non-genetically modified microalgae, which is naturally high in the omega-3 fatty acid, DHA. This microalgae is in fact the source of DHA for fish in their foodchain.

Schizochytrium sp. (microalgae) sourced from life’s DHA is grown in a controlled environment and is a sustainable source of DHA naturally free of ocean-borne contaminants.

PROBIOTICS

Probiotics are emerging as one of the most promising fields of medicine. Their importance in healthy pregnancy & birth and following that, in the first stages of life is not to be underestimated. 

You can find more information on the benefits of probiotics in pregnancy and breastfeeding here:

 

REFERENCES

  1. Elevit. 2012. Complaints Resolution Panel; Therapeutic Goods Administration. [Link

  2. Goh YI, Bollano E, Einarson TR, et al. Prenatal mulitvitamin supplementation and rates of congenital abnormalities: a meta-analysis. JObstet Gynaecol Canada 2006;28(8):680-689. [Abstract
     
  3. Zagre NM, Desplats G, Adou P, et al. Prenatal multiple micronutrient supplementation has greater impact on birthweight than supplementation with iron and folic acid: A cluster-randomized, double- blind, controlled programmatic study in rural Niger. Food andNutrition Bulletin 2007;28(3):317-327. The United Nations University. [Full Text
     
  4. Australian Govt., Dept. of Health & Ageing, NHMRC. Nutrient Reference Values for Australia & New Zealand. 2006. [Link
     
  5. Bovell-Benjamin AC, Viteri FE, Allen LH. Iron absorption from ferrous bisglycinate and ferric trisglycinate in whole maize is regulated by iron status. Am J Clin Nutr 2000 Jun;71(6):1563-1569. [Full Text
     
  6. Coplin M, Schuette S, Leichtmann G, et al. Tolerability of iron: a comparison of bis-glycino iron II and ferrous sulfate. Clin Ther 1991 [Abstract
     
  7. Ziaei S, Norrozi M, Faghihzadeh S, et al. A randomised placebo-controlled trial to determine the effect of iron supplementation on pregnancy outcome in pregnant women with haemoglobin > or = 13.2 g/dl. BJOG 2007 Jun;114(6):684-688. [Full Text
     
  8. Australian Institute of Health & Welfare. Mandatory folic acid and iodine fortification in Australia and New Zealand - October 2001. [Link]
     
  9. Food Standards Australia New Zealand. Fortification of Food with Folate and Iodine. [Link]
     
  10. Olivares JL, Olivi GI, Verdasco C, et al. Low iodine during pregnancy: relationship to placental development and head circumference in newborn. Endocrinol Nutr 2012;59(5):326-330. [Abstract
     
  11. Pearce EN. Effects of iodine deficiency in pregnancy. J Trace Elem Med Biol 2012 Jun;26(2-3):131-133. [Abstract
     
  12. Zimmermann MB. The effects of iodine deficiency in pregnancy and infancy. Paediatric and Perinatal Epidemiology 2012;26(suppl.1):108-117. [Full Text
     
  13. Kaludjerovic J, Vieth R. Relationships between vitamin D during perinatal development and health. J Midwifery Womens Health 2010 Nov-Dec;55(6):550-560 [Abstract
     
  14. Lapillone A. Vitamin D deficiency during pregnancy may impair maternal and fetal outcomes. Med Hypotheses 2010 Jan;74(1):71-75. [Abstract
     
  15. Mannion CA, Gray-Donald K, Koski KG. Association of low intake of milk and vitamin D during pregnancy with decreased birth weight. CMAJ 2006 Apr 25;174(9):1273-1277. [Full Text
     
  16. Javaid MK, Crozier SR, Harvey NC, et al. Maternal vitamin D status during pregnancy and childhood bone mass at age 9 years: a longitudinal study. Lancet 2006;367(9504):36-43 [Abstract
     
  17. Munns C, Zacharin MR, Rodda CP, et al. Prevention and treatment of infant and childhood vitamin D deficiency in Australia and New Zealand: a consensus statement. MJA 2006;185(5):268-272. [Full Text
     
  18. Robinson PD, Hogler W, Craig ME, et al. The re-emerging burden of rickets: a decade of experience from Sydney. Arch Dis Child 2006;91(7):564-568. [Full Text
     
  19. Singh M. Essential fatty acids, DHA and human brain. Indian J Paediatr 2005;72(3):239-242 [Abstract
     
  20. Kendall-Tackett KA. Depression in new mothers. Causes, consequences, and treatment alternatives. Second edition, 2010. Routledge,USA.
     
  21. Kendall-Tackett K. Long-chain omega-3 fatty acids and women’s mental health in the perinatal period and beyond. J Midwifery Womens Health 2010 Nov-Dec;55(6):561-567 [Abstract
     

DISCLAIMER: 

The information provided on FX Medicine is for educational and informational purposes only. The information provided on this site is not, nor is it intended to be, a substitute for professional advice or care. Please seek the advice of a qualified health care professional in the event something you have read here raises questions or concerns regarding your health. 

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rebeccaguild's picture
Rebecca Guild
Rebecca is a Naturopath having graduated in 2003 with an Adv.Dip Naturopathy and Western Herbal Medicine. Rebecca has worked in pharmacy, her own clinic and for one of Australia's largest professional supplement companies, and more recently as the editor and curator for FX Medicine. Rebecca is now involved in complementary medicine education, sales and marketing, digital & social media and is a passionate advocate of naturopathic medicine in the Integrative Health Model. She has a special interest in the regulatory landscape of naturopathic medicine and likes to inspire current and future students to strive for meaningful careers in the industry.