Pregnant Women Archives - Health Tips From The Professor

Is Fluoride Safe For Pregnant Women?

July 23, 2024 by Dr. Steve Chaney

What Does This Study Mean For You?

Author: Dr. Stephen Chaney

Fluoridation of drinking water has always been controversial. On one side you have the dental and medical community who claim that fluoridation is a great public health advance. Their claim is that it strengthens teeth and prevents tooth decay with minimal risk to the public.

Although my dentist tells me that most of the “benefits” of fluoridation can be achieved with good dental hygiene. Fluoridation is just another example of the American public’s reliance on drugs and chemicals as a “quick fix” rather than taking the personal responsibility to make healthy lifestyle changes.

On the other side you have people who claim that fluoride is toxic at any level. Their claim is that there are many health issues with fluoridation that have been ignored by the dental and medical community. Their claims are that excess fluoride exposure increases the risk of:

Dental fluorosis (A discoloration of the teeth that is caused by overexposure to fluoride during childhood).

Bone fractures (Paradoxically, fluoride makes bones and teeth stronger, but it also makes them more fragile).

Arthritis.

Some types of cancer.

And in the middle are those who believe that fluoridation has both benefits and risks. They believe we should identify the risks, so we can advise people appropriately.

The study (AJ Main et al, JAMA Network Open, 2024; 7(5):e2411987) I will discuss today falls into this category. It also illustrates the difficulty in doing high-quality research on risks associated with fluoridation, which I will discuss.

How Was This Study Done?

The data for this study were obtained from the MADRES (Maternal and Developmental Risks from Environmental and Social Stressors) database. The women in this study were predominantly Hispanic women of low socioeconomic status who were recruited from prenatal clinics in Los Angeles serving predominantly medically underserved communities starting in 2015.

Maternal urinary fluoride (MUF) levels were measured during the third trimester of pregnancy between 2017 and 2020. The average MUF was 0.76 mg/dL, which is similar to the average MUF for women in this country. However, there was a broad range in MUF, so the women in this study were divided into quartiles based on their MUF score.

Their child’s score on the Preschool Behavior Checklist was measured at 36 months between 2020 and 2023. The Preschool Behavior Checklist is a 99-item questionnaire. The questionnaire measures 7 syndromes:

Emotionally reactive, anxious-depressed, somatic complaints (physical symptoms with no clear cause), withdrawal, sleep problems, attention problems, opposition-defiant problems, and aggressive behavior.

These symptoms are then used to calculate scores for two classes of problems:

Internalizing problems (anxiety, depression, somatic complaints, withdrawal, sleep problems).

Externalizing problems (attention problems, oppositional-defiant and aggressive behavior).

The questionnaire was also designed to provide scores for autism spectrum problems and ADHD problems.

Based on previous usage of the Preschool Behavior Checklist each of these scores can be divided into normal, borderline clinical problems, and clinical problems.

Is Fluoride Safe For Pregnant Women?

When comparing women in the highest Maternal Urinary Fluoride (MUF) quartile in the third trimester to women in the lowest quartile, their children at age 36 months:

Were 83% more likely to have a combination of internalizing and externalizing behavior problems in the borderline clinical and clinical range.

Were 84% more likely to have a combination of internalizing and externalizing behavior problems in the clinical range.

Were 18.5% more likely to have symptoms characteristic of autism spectrum disorder.

Were 11.3% more likely to have anxiety symptoms.

Were 19.6% more likely to have somatic complaints (symptoms with no clear cause).

The authors concluded, “These findings suggest that prenatal fluoride exposure may increase risk of neurobehavioral problems among children living in optimally fluoridated areas in the US. These findings suggest there may be a need to establish recommendations for limiting exposure to fluoride during the prenatal period, a time when the developing brain is known to be especially vulnerable to injury from environmental insults.”

What Are The Strengths And Weaknesses Of This Study?

This is the first study of its kind in the United States. As such it should be regarded as a “proof of principle” study that needs to be confirmed by larger follow-up studies. However, it is fully consistent with two larger studies published in Canada and Mexico.

As a “proof of principle study, it does have some limitations, namely:

It was performed with a Hispanic population of low socioeconomic status and limited access to healthcare. It needs to be repeated with other population groups to see if it is generalizable to the general population. This is important because, if there is a need to make a recommendation to minimize fluoride intake during pregnancy, we need to know whether that recommendation applies to all women or just to certain high-risk groups.

It is an association study which does not prove cause and effect. Ideally, it should be followed by placebo-controlled intervention studies to prove cause and effect.

It is a very small study. Ideally, it should be followed by much larger studies.

However, it is unlikely that either of those follow-up studies will be done. It would cost hundreds of thousands of dollars to conduct large-scale studies – especially if they were placebo-controlled intervention studies. And with the dental and medical community fully convinced fluoridation has no risks, it would be very difficult to get that kind of money.

Even if that money were available, 73% of US communities have fluoridated water. Plus, most bottled beverages in the US are made with fluoridated water. So, it would not be easy to find a suitable control population for a placebo-controlled intervention study.

What Does This Study Mean For You?

As I shared above, this is a “proof of principle” study. It suggests, but does not prove, fluoride exposure during pregnancy may increase the risk of neurobehavioral issues with your offspring.

However, I also realize that if you are pregnant or thinking of becoming pregnant and you spend any time on the internet, you are bombarded with all the things you must avoid if you want to have a healthy baby. I don’t want to add to your anxiety.

So, let’s assume the conclusions of this article might be true. What can you do?

With respect to drinking water, the answer is simple:

Drink filtered water or bottled water.

- Most filtration systems remove fluoride (make sure yours does).

- Many bottled waters do not contain fluoride. Read the label to be sure:

- - If it is bottled tap water, it probably contains fluoride.

- - If it is spring water, the fluoride would have to be added and would appear on the label.

- - If it is filtered or distilled water, it does not contain fluoride.

Since municipal water supplies often contain low levels of other contaminants, this is a good idea even if you aren’t pregnant.

With respect to bottled beverages, the answer is more complex.

The list of beverages made with fluoridated municipal water is a long one. It includes sodas, energy drinks, teas, fruit juices “made from concentrate”, and much more.

However, you already know that most of these beverages are bad for you because they contain added sugar and/or a long list of artificial ingredients. Substituting filtered water or fluoride-free bottled water for them is a good idea whether you are pregnant or not.

The Bottom Line

A recent study looked at the correlation between fluoride intake during pregnancy and neurobehavioral issues in the children at 36 months.

When comparing pregnant women with the highest fluoride intake to women with the lowest fluoride intake, their children at age 36 months:

Were 83% more likely to have behavior problems.

Were 18.5% more likely to have symptoms characteristic of autism spectrum disorder.

Were 11.3% more likely to have anxiety symptoms.

Were 19.6% more likely to have somatic complaints (symptoms with no clear cause).

For more details on this study and what it means for you, read the article above.

These statements have not been evaluated by the Food and Drug Administration. This information is not intended to diagnose, treat, cure or prevent any disease.

______________________________________________________________________________

My posts and “Health Tips From the Professor” articles carefully avoid claims about any brand of supplement or manufacturer of supplements. However, I am often asked by representatives of supplement companies if they can share them with their customers.

My answer is, “Yes, as long as you share only the article without any additions or alterations. In particular, you should avoid adding any mention of your company or your company’s products. If you were to do that, you could be making what the FTC and FDA consider a “misleading health claim” that could result in legal action against you and the company you represent.

For more detail about FTC regulations for health claims, see this link.

https://www.ftc.gov/business-guidance/resources/health-products-compliance-guidance

_______________________________________________________________________

About The Author

Dr. Chaney won numerous teaching awards at UNC, including the Academy of Educators “Excellence in Teaching Lifetime Achievement Award”.

Dr Chaney also ran an active cancer research program at UNC and published over 100 scientific articles and reviews in peer-reviewed scientific journals. In addition, he authored two chapters on nutrition in one of the leading biochemistry text books for medical students.

Since retiring from the University of North Carolina, he has been writing a weekly health blog called “Health Tips From the Professor”. He has also written two best-selling books, “Slaying the Food Myths” and “Slaying the Supplement Myths”. And most recently he has created an online lifestyle change course, “Create Your Personal Health Zone”. For more information visit https://chaneyhealth.com.

For the past 45 years Dr. Chaney and his wife Suzanne have been helping people improve their health holistically through a combination of good diet, exercise, weight control and appropriate supplementation.

Which Nutrients Prevent Prenatal Depression?

May 14, 2024 by Dr. Steve Chaney

What Does This Study Mean For You?

Author: Dr. Stephen Chaney

Yes, you read the headline correctly. Everyone talks about postnatal depression. But prenatal depression is also a “thing”, especially during the third trimester.

Worldwide, 4-20% of women experience some degree of depression during the third trimester – with pregnant women in high-income countries at the lower end (4-10%) of depression risk.
In contrast, the incidence of postnatal depression is 10-15%.

It is probably no coincidence that the incidence of depression is greatest during the third trimester and during the postnatal period.

The third trimester is the most difficult part of pregnancy for many women.
When a woman brings her baby home from the hospital her orderly life becomes chaotic.

But what role does nutrition play?

While not definitive, many studies suggest that supplementation with B vitamins, especially folic acid, B6, and B12; omega-3 fatty acids; vitamin D; and iron reduce the risk of postnatal depression.
However, there is much less information on which nutrients reduce the risk of prenatal depression.

Based on studies suggesting both iron and vitamin D deficiencies may negatively impact mental health, the authors of this study (JL Evanchuk et al, The Journal Of Nutrition. 154, 174-184, 2024) set out to determine whether iron and/or vitamin D deficiencies increase the risk of prenatal depression during the first trimester.

How Was This Study Done?

The authors recruited 2189 newly pregnant mothers from Calgary and Edmonton in Ontario Canada between 2009 and 2012. Participants in the study visited clinics in the area upon entry into the study; midway through the first, second, and third trimesters; and at multiple timepoints up to 3 months during the postpartum period.

In addition to the usual pregnancy wellness tests, participants filled out a 24-hour dietary recall and a Supplemental Intake Questionnaire to determine intakes of iron and vitamin D.

Note: The participants were all advised to take some form of prenatal supplement during the study. That’s because prenatal supplements are considered “the standard of care” for pregnant woman, so it would be considered unethical not to include a prenatal supplement in this study.

At the mid-point of the second trimester blood samples were drawn and analyzed for biomarkers of iron and vitamin D insufficiency. For iron the biomarkers were serum ferritin, soluble transferrin receptor, and hepcidin. For vitamin D, the biomarkers were 25-hydroxyvitamin D, 1,25-dihydroxyvitamin D, and 3-epi-25-hydroxyvitamin D.

Iron deficiency was defined as serum ferritin levels <15 µg/L. Vitamin D insufficiency was defined as 25-hydroxyvitamin D levels < 75nmol/L. The other biomarkers were used to confirm these diagnoses.

Maternal depression was measured midway through the third trimester and ~3 months postpartum using 10-item questionnaire called the Edinburg Postnatal Depression Scale (EPDS). The EPDS ranks depression on a scale of 0 to 30, with a score of ≥13 considered an indication of likely depression.

The characteristics of the women enrolled in this study were:

Average age = 31.5
Average prepregnancy BMI = 23 (healthy weight).
Married or cohabitating with a partner = 97%.
Highly educated (college or postgraduate degree) = 68%.
Income above $70,000/year = 78%.
First child = 54%.
White = 80%.

Based on the Edinburg Depression Scale, probably depression for the 1822 women who completed the study was 5.6% during the third trimester and 4.4% 3 months postpartum.

Note: The low incidence of depression seen in this study was probably due to:

The women in this study were of high socioeconomic status and were receiving excellent healthcare.

The women in this study were taking prenatal supplements that provided both iron and vitamin D.

Which Nutrients Prevent Prenatal Depression?

As I mentioned when describing how the study was designed, all participants in this study were advised to take a prenatal supplement. Consequently:

94% of the women in this study were taking a supplement containing iron with an average supplemental iron intake of 26 mg/day.

- Note: The RDA for iron during pregnancy is 30 mg/day and most prenatal supplements provide 27 mg/day.

68% of the women in this study were taking a supplement containing vitamin D, with an average supplemental vitamin D intake of 330 IU/day.

- Note: The RDA for vitamin D during pregnancy is 600 IU/day, but most prenatal supplements provide far less than that.

When the investigators looked at iron and vitamin D status during the second trimester:

63.3% of the women had adequate levels of both iron and vitamin D.

14.8% of the women were low in vitamin D but had adequate iron levels.

18.4% of the women were low in iron but had adequate levels of vitamin D.

3.5% of the women were low in both iron and vitamin D.

RDAs are supposed to be enough to meet the nutrient requirements of 97-98% of healthy individuals, so it is perhaps surprising to see so many women with insufficient levels of iron (21.9%) and/or vitamin D (18.3%) in this study. This could be due to:

Insufficient intake.

- This is a likely explanation for vitamin D because the supplements women were using in this study provided around half the recommended RDA for vitamin D and the women lived at a northern latitude where sun exposure makes a small contribution to vitamin D levels.

- However, this is a less likely explanation for insufficient iron levels because the supplements provided 87% of the RDA for iron.

Inadequate RDAs. Studies like this one provide a rigorous test for the adequacy of existing RDAs. This study suggests the existing RDA for iron is adequate to meet the needs of ~80% of pregnant women, which is reassuring. However, it may need to be increased to reach the goal of meeting the iron requirements for 97-98% of pregnant women.

But the important question is whether the iron and vitamin D insufficiencies seen in this study mattered. The data suggested that they did.

For pregnant women with low iron, but adequate vitamin D levels in the second trimester, there was a small, but significant, increased risk of experiencing depression symptoms in the third trimester.

For pregnant women with low iron and vitamin D levels in the second trimester, the risk of experiencing depression symptoms in the third trimester increased by 2.2 points in the 30-point Edinburg Depression Scale.

- This is equivalent to a 7.4% increased risk of depression from deficiencies of iron and vitamin D alone – and these are only 2 of at least 8 nutrients thought to be associated with maternal depression.

The authors concluded, “Maternal iron and vitamin D biomarkers, measured during midpregnancy, were independently associated with third trimester maternal depression symptoms…This investigation is one of the first to report on the combined adequacy of maternal iron and vitamin D status during pregnancy and its impact on maternal depression.

The novelty of this work reinforces the need to ask similar questions [with other nutrients and] in other pregnant populations. Future investigations should report on the status of multiple nutrients and explore their independent and combined impact on health outcomes of pregnant individuals and their children.”

What Does This Study Mean For You?

Depression during pregnancy is bad for you. And because your fetus can sense your mood, it is bad for your baby. So, what should you do?

You can consult with your doctor about which antidepressants are safe to take during pregnancy. But the truth is there are no good choices. There are some antidepressants that are off limits. There are other antidepressants that appear to have little short-term risks, but we have no idea if there are long-term risks for your child.

So, what about natural approaches? Let’s start with nutrition.

The biggest takeaway from this study is that prenatal supplements may not be sufficient to prevent nutritional deficiencies that may cause prenatal depression for pregnant women.

This does not mean that every pregnant woman suffering prenatal depression should increase their iron and vitamin D levels.

However, if you are experiencing prenatal depression, you might want to ask your doctor about checking your iron and vitamin D status to determine if extra iron and/or vitamin D would be beneficial.

And to put this study into its proper perspective we need to remember that iron and vitamin D deficiencies are only two of many nutrients that may increase the risk of prenatal depression.

For example, in addition to iron and vitamin D, prenatal depression is associated with deficiencies of:

B vitamins, especially folate, B6 and B12. Most prenatal supplements provide the recommended RDA of folate for pregnant women, but not all contain RDA amounts of B6 and B12.

Calcium and magnesium. Very few prenatal supplements provide the recommended RDA for calcium and magnesium.

Omega-3s, especially DHA. Very few prenatal supplements provide DHA, and the few that do usually provide inadequate amounts of DHA.

So, when you are having your nutrition conversation with your doctor, you might not want to limit your conversation to iron and vitamin D.

Alternately, as I suggested last week’s issue of “Health Tips From the Professor”, you might wish to add a multivitamin supplement and an omega-3 supplement providing at least 300 mg of DHA plus EPA. This simple step would be sufficient to assure you have adequate levels of nutrients thought to be important for reducing the risk of prenatal depression.

And, of course, there are other lifestyle factors, as well. For example:

Diets high in highly processed foods are known to increase the risk of depression. And whole food, primarily plant-based diets decrease the risk of depression.

Overweight and obesity increase the risk of depression.

Regular exercise decreases the risk of depression.

The Bottom Line

A recent study looked at whether taking a prenatal supplement was sufficient to eliminate deficiencies of iron and vitamin D during pregnancy and whether deficiencies of these two nutrients during the second trimester of pregnancy increased the risk of depression during the third trimester.

When the investigators looked at iron and vitamin D status during the second trimester:

14.8% of the women were low in vitamin D but had adequate iron levels.

18.4% of the women were low in iron but had adequate levels of vitamin D.

3.5% of the women were low in both iron and vitamin D.

But the important question is whether the iron and vitamin D insufficiencies seen in this study mattered. The data suggested that they did.

For pregnant women with low iron, but adequate vitamin D levels in the second trimester, there was a small, but significant, increased risk of experiencing depression symptoms in the third trimester.

For pregnant women with low iron and vitamin D levels in the second trimester, the risk of experiencing depression symptoms in the third trimester increased by 2.2 points in the 30-point Edinburg Depression Scale.

This is equivalent to a 7.4% increased risk of depression from deficiencies of iron and vitamin D alone.

When you consider that iron and vitamin D are just two of 8 or more nutrients thought to be important for preventing depression during pregnancy, the question becomes what you can do to decrease your risk of developing depression during pregnancy and after the birth of your child.

For more details about the study and what it means for you, read the article above.

These statements have not been evaluated by the Food and Drug Administration. This information is not intended to diagnose, treat, cure, or prevent any disease.

____________________________________________________________________________

For more detail about FTC regulations for health claims, see this link.

https://www.ftc.gov/business-guidance/resources/health-products-compliance-guidance

___________________________________________________________________________

About The Author

Dr. Chaney has a BS in Chemistry from Duke University and a PhD in Biochemistry from UCLA. He is Professor Emeritus from the University of North Carolina where he taught biochemistry and nutrition to medical and dental students for 40 years. Dr. Chaney won numerous teaching awards at UNC, including the Academy of Educators “Excellence in Teaching Lifetime Achievement Award”. Dr Chaney also ran an active cancer research program at UNC and published over 100 scientific articles and reviews in peer-reviewed scientific journals. In addition, he authored two chapters on nutrition in one of the leading biochemistry text books for medical students.

What Nutrients Are Missing In Prenatal Supplements?

May 7, 2024 by Dr. Steve Chaney

Do These Deficiencies Matter?

Author: Dr. Stephen Chaney

If you are a pregnant mom, nothing is more important than the health of your baby. And if you are pregnant or thinking of becoming pregnant, your doctor has probably recommended a prenatal supplement. But does the prenatal supplement he or she recommended provide you with all the nutrients you need?

In a previous issue of “Health Tips From the Professor” I shared two studies that suggested the answer is, “No”. Those studies concluded that most prenatal supplements had little or no vitamin K, choline, DHA, and iodine – all of which are essential for the health of your newborn baby. And while most prenatal supplements contained calcium, the amount they provided was far below recommended levels.

The authors of the first study also made the point that most women going on a prenatal supplement will probably discontinue taking their multivitamin supplement, so a good prenatal supplement should provide all the essential nutrients.

But they don’t. Folic acid, iron, calcium, and vitamin D have long been recognized as essential for a healthy pregnancy. So, virtually every prenatal supplement contained these four nutrients, although calcium is often present in suboptimal amounts. Beyond those four nutrients, the design of prenatal supplements is haphazard. Some contain vitamin K, choline, iodine, or DHA (often in suboptimal amounts). But almost none contain all four nutrients.

And when you consider the other essential nutrients you find in most multivitamins, prenatal supplements often come up empty. Is that a problem? That’s what this study (KM Godfrey et al, PLOS Medicine, 1-27, December 5, 2023) was designed to find out.

How Was This Study Done?

This was a double-blind, placebo-controlled clinical trial, the gold standard for clinical studies. The investigators recruited 1,729 women who were planning to get pregnant from England, Singapore, and New Zealand between 2015 and 2017.

The women were randomly split into two groups:

The control group received a supplement containing nutrients that were most frequently included in prenatal supplements in those countries (folic acid, iron, calcium, iodine, and beta-carotene).

The intervention group received a supplement containing those nutrients plus riboflavin, vitamin B6, vitamin B12, vitamin D, zinc, inositol, and probiotics).

Riboflavin, vitamin B6, vitamin B12, vitamin D, and zinc were included because they are included in most multivitamins but are often missing in prenatal supplements.

Inositol was included because some studies have suggested that inositol may reduce the risk of maternal hyperglycemia and gestational diabetes.

Blood samples to assess nutritional status were obtained from all women in the study before the trial started (baseline) and after 1 month of supplementation with either the control or intervention formulation.

Of the women entering the study, 512 went on to have a singleton (one child) pregnancy. For these women supplementation was continued until childbirth. Additional blood samples were obtained in early and late pregnancy and at 6 months postdelivery. [Note: no supplementation was provided to either group postdelivery. And this is also a period of time when most women would be breastfeeding.]

The blood samples were tested for:

Blood levels of folic acid, riboflavin, vitamin B6, vitamin B12, and vitamin D.

Functional biomarkers of deficiencies of each of these vitamins.

What Nutrients Are Missing In Prenatal Supplements?

There was no difference in maternal hyperglycemia or gestational diabetes between the control group and the intervention group supplemented with inositol, so I will focus on the other nutrients present in the intervention group.

At baseline when subjects were first entered into the study.

29.2% of the subjects had low or marginal status for folic acid.

82.0% of the subjects had low or marginal status for riboflavin.

1.3% of the subjects had low or marginal status for vitamin B6.

9.1% of the subjects had low or marginal status for vitamin B12.

48.7% of the subjects had low or marginal status for vitamin D.

91.0% of the subjects had low or marginal status for one or more of these vitamins.

In the control group receiving folic acid but no riboflavin, vitaminB6, vitamin B12, and vitamin D:

Folic acid deficiency fell to 4.1% after 1 month of supplementation (the supplement used by the control group contained folic acid), 1% in early pregnancy, 6.1% in late pregnancy, and rose to 31.8% 6 months after supplementation was discontinued. The intervention group got the same amount of folic acid, and their results were similar.

Riboflavin deficiency ranged from 82-92% during pregnancy and returned to 82% 6 months postdelivery.

Vitamin B6 deficiency increased to 54% in late pregnancy and returned to 1.2% 6 months postdelivery.

Vitamin B12 deficiency increased to 55% in late pregnancy and returned to 12.4% 6 months postdelivery.

Vitamin D deficiency ranged from 35-43% during pregnancy and returned to 31% 6 months postdelivery.

Functional markers of vitamin B6 deficiency were evident by late pregnancy.

In short, data from the control group fell into 3 categories:

The data with folic acid confirm previous studies showing that folic acid in the amount present in most prenatal supplements is effective at preventing folic acid deficiency before and during pregnancy. It also strengthens the argument for continuing folic acid supplementation during breastfeeding.

Deficiencies of riboflavin and vitamin D are prevalent in women of childbearing age, but pregnancy does not appear to significantly impact the percentage of women who are deficient in these nutrients.

Deficiencies of vitamins B6 and B12 are rare in women of childbearing age, but pregnancy significantly depletes both nutrients.

- This was particularly evident for vitamin B6. Blood levels of vitamin B6 markers decreased to a level that could impact the functioning of vitamin B6-depended metabolic pathways.

For the intervention group receiving additional riboflavin, vitamin B6, vitamin B12, and vitamin D:

Deficiencies of these vitamins were eliminated by one month of supplementation.

Vitamin levels remained adequate during pregnancy.

Except for vitamin B12, deficiencies of these vitamins reappeared when supplementation was discontinued for 6 months. The maintenance of adequate B12 levels 6 months after supplementation stopped was expected because the body holds on to its B12 stores very tightly.

In short deficiencies of these nutrients before and during pregnancy could be eliminated by supplementation with levels of these nutrients found in many multivitamins.

The authors concluded, “Over 90% of the trial participants had low concentrations of one or more of folate, riboflavin, vitamin B12, or vitamin D during preconception, and many developed markers of vitamin B6 deficiency in late pregnancy. Preconception/pregnancy supplementation in amounts available in over-the-counter supplements substantially reduces the prevalence of vitamin deficiency and depletion markers before and during pregnancy, with higher maternal plasma vitamin B12 maintained during the recommended lactation period.”

Do These Deficiencies Matter?

It is well established that deficiencies of folic acid and vitamin D cause health risks for the mother and developmental risks for the fetus, so I won’t discuss these nutrients here.

However, the effect of riboflavin, vitamin B6, and vitamin B12 deficiencies on pregnancy is less well known, which is probably why these nutrients are often not added to prenatal supplements.

The authors of the study said small studies have suggested that:

Low or deficient riboflavin status may be associated with a higher risk of anemia during pregnancy.

Low vitamin B6 status may be associated with an increased risk of preterm birth and development of metabolic health risks in the child.

Low vitamin B12 status may be associated with increased risk of gestational diabetes and pre-eclampsia in the mother, and increased risk of neural tube defects, preterm birth, low birth weight, and neurocognitive delays in the baby – with the strongest evidence being an effect on neurocognitive development.

While none of these risks have been definitively proven, the authors point out that deficiencies of these nutrients can easily be eliminated with inexpensive, over-the-counter multivitamin supplements.

What Does This Study Mean For You?

Perhaps I should start this section by asking why these deficiencies are so common in women of child-bearing age.

The authors speculate that part of the reason is that many women are giving up meat (B12 and iron) and dairy (calcium and riboflavin) for health or environmental reasons.

However, they also point out that a more likely cause is that more than 60% of calories consumed in countries like England, New Zealand, and the United States comes from ultra-processed foods – otherwise known as “empty calories”.

Whatever the cause, the authors conclude, “…the findings suggest a need to reappraise dietary recommendations for preconception and pregnancy to consider further the role of multiple micronutrient supplements for women living in higher-income countries.” I agree.

In a previous “Health Tips From the Professor” article, I reported a recent study showing that most prenatal supplements have either no or inadequate amounts of vitamin K, choline, DHA, iodine, and calcium, nutrients that are absolutely essential for a healthy pregnancy. And I gave recommendations for choosing the best prenatal supplement for you and your child.

That study also noted that many women discontinue their multivitamin supplement when they start taking a prenatal supplement. The current study indicates that practice may be unwise. It shows that:

Many women of childbearing age are deficient in one or more of these essential nutrients, and…

Essential nutrients not found in most prenatal supplements may also be important for a healthy pregnancy.

So, if you are pregnant or thinking of becoming pregnant, follow this article’s recommendation to start with a well-designed prenatal supplement that provides adequate amounts of folate, iron, calcium, vitamin D, vitamin K, choline, DHA, and iodine and add a multivitamin supplement that provides the other essential nutrients. Alternatively, a simpler approach would be to choose a well-designed prenatal supplement that includes all the essential nutrients. That would be my recommendation.

I would also note this study showed that deficiencies of most of these nutrients reappeared as soon as supplementation was discontinued. Although the authors of this study did not mention it, this reinforces the importance of continuing supplementation during breastfeeding.

The Bottom Line

I have previously reported on a study that concluded many prenatal supplements lack one or more nutrients shown to be important for a healthy pregnancy. But let’s say you have found a prenatal supplement that provides all those nutrients. Is that enough?

Studies show that most women stop taking their multivitamin supplement when they start on a prenatal supplement. But is that a good idea? Are there essential nutrients found in multivitamins, but not in many prenatal supplements that are also important for a healthy pregnancy?

A recent study asked that question in women who were trying to become pregnant. The study found that:

Many women of childbearing age are deficient in one or more essential nutrients found in multivitamin supplements but often missing in prenatal supplements, and…

Essential nutrients not found in most prenatal supplements may also be important for a healthy pregnancy.

For more details about this study and what it means for you read the article above.

These statements have not been evaluated by the Food and Drug Administration. This information is not intended to diagnose, treat, cure, or prevent any disease.

______________________________________________________________________________

For more detail about FTC regulations for health claims, see this link.

https://www.ftc.gov/business-guidance/resources/health-products-compliance-guidance

______________________________________________________________________

About The Author

Is Vegan Breast Milk Sufficient?

June 27, 2023 by Dr. Steve Chaney

What Can Vegan Moms Do?

Author: Dr. Stephen Chaney

A whole food vegan diet is incredibly healthy:

Vegans are less likely to be overweight than the general population.

Vegans have a lower risk of diabetes, heart disease, cancer, hypertension, and several other diseases than the general population.

Whole food vegan diets are anti-inflammatory, so they lower the risk of autoimmune diseases and the “itis” diseases.

But vegan diets leave out meat, dairy, and eggs. Vegetarians without proper dietary advice are at high risk of inadequate intake of vitamin B12, vitamin D, iron, iodine, calcium, and DHA. And, of course, the risk of inadequate intake is even greater for vegans than it is for vegetarians, who may include some dairy and eggs in their diet.

So, it is legitimate to ask whether a vegetarian or vegan diet is sufficient for pregnancy and lactation. The short answer is that they can be if they are properly designed and properly supplemented.

But that is not an easy task, as evidenced by a recent study (N Ureta-Velasco et al., Nutrients 15:1855, 2023) comparing the breast milk of omnivore moms with the breast milk of vegetarian and vegan moms.

How Was This Study Done?

This study was done with 92 omnivore moms, 9 vegetarian moms (5-ovo-vegetarian and 4 lacto-ovo-vegetarians) and 11 vegan moms between August 2017 and February 2020 at the Regional Human Milk Bank at the “12 de Octubre” University Hospital in Madrid, Spain. The vegetarian and vegan moms were grouped together for data analysis.

On Day 0 of the study, participants went to the regional milk bank for blood and urine samples to determine nutritional status, a screening to determine health and socioeconomic status, and for food frequency questionnaire to characterize their habitual diet.

On days 1-5, they returned to the regional milk bank with a 24-hour diet recall of the previous day and to express 25 ml of breast milk to determine its nutrient content. On day 6, they returned to express a larger sample of breast milk to determine its lipid content (including EPA and DHA).

Note: Both the food frequency questionnaire and the 24-hour dietary recalls included nutrients derived from supplements.

What Did The Study Show About Dietary Intake of Key Nutrients?

This was a comprehensive study, so I will just cover the highlights here:

Birth Weight: Compared to the children of omnivore moms, the children of vegetarian/vegan moms were more likely to:

Have less weight gain during pregnancy (2 pounds less on average).

Be underweight at birth (60% of babies born to vegetarian/vegan moms were in the underweight category of birth weights versus 25% for babies born to omnivore moms).

This is probably because vegetarian/vegan moms:

Consumed slightly fewer calories per day (2146 versus 2319).

Consumed significantly less protein (67 g/d versus 96 g/d).

Were 10 times more likely to be underweight prior to pregnancy (10% versus 1%).

This is a concern because low birth weight increases the risk of physical and mental health issues later in life.

Supplement Use: The nutrients of greatest concern in a vegetarian/vegan diet are vitamin B12, vitamin D, iron, iodine, calcium, and DHA. For all these nutrients except DHA, this message appears to have gotten out to most vegetarian/vegan mothers because they were compensating for these potential deficiencies through supplementation.

For example, when they looked at average daily intake of these key nutrients from supplements, they found:

Nutrient	Vegetarian/Vegan Moms	Omnivore Moms
Vitamin D	1,080 IU (27mcg)	240 IU (6 mcg)
Folic acid	400 mcg	280 mcg
Vitamin B12	312 mcg	2 mcg
Calcium	566 mg	164 mg
Iron	40 mg	29 mg
DHA	100 mg	180 mg

However, that doesn’t tell the whole story, because not all vegetarian/vegan moms took supplements. When the investigators looked at the percent taking supplements, this is what they found.

Nutrient	Vegetarian/Vegan Moms	Omnivore Moms
Vitamin D	50%	50%
Folic acid	35%	61%
Vitamin B12	85%	60%
Calcium	15%	37%
Iron	25%	43%
DHA	10%	16%

Dietary Intake (Food + Supplements): The extra supplementation clearly played an important role because when the investigators looked at the overall intake from food and supplements, they found:

Nutrient	Vegetarian/Vegan Moms	Omnivore Moms
Vitamin D	224 IU (5.6 mcg)	432 IU (10.8 mcg)
Folate + Folic acid	668 mcg	473 mcg
Vitamin B12	258 mcg	6.9 mcg
Calcium	910 mg	1148 mg
Iron	31 mg	25 mg
DHA	110 mg	380 mg

Again, this doesn’t tell the whole story. Some women didn’t supplement. When the investigators looked at the percentage of women getting an inadequate intake of key nutrients from food plus supplements they found:

Nutrient	Vegetarian/Vegan Moms	Omnivore Moms
Vitamin D	75%	88%
Folate + Folic acid	0%	39%
Vitamin B12	25%	0%
Calcium	45%	40%
Iron	Not reported	Not reported
DHA	Not reported	Not reported

These results clearly show the need for supplementation. While the average intake from food plus supplements looked good, there were a significant percentage of women who weren’t getting adequate intake of key nutrients because they didn’t supplement.

The exceptions were folate + folic acid for vegetarian/vegans because their diet is rich in folate-containing foods and vitamin B12 for omnivores because their diet is rich in foods containing B12.

Is Vegan Breast Milk Sufficient?

Of course, the proof is in the pudding. When the investigators looked at the nutrient content of breast milk, this is what they found:

Nutrient	Vegetarian/Vegan Moms	Omnivore Moms	Reference Value*
Vitamin D3	1.1 mcg/L	3.4 mcg/L	0.25-2 mcg/L
Folate + Folic acid	19 mcg/L	20 mcg/l	80 mcg/L
Vitamin B12	0.74 mcg/L	0.65 mcg/L	0.5 mcg/L
Calcium	83 mg/L	99 mg/L	200-300 mg/L
Iron	Not reported	Not reported
DHA	0.15 g/100 g fat	0.33 g/100 g fat	0.35 g/100 g fat

*Reference values established by WHO

The chief difference between breast milk from vegetarian/vegan moms was in DHA levels.

That’s because the diet of vegetarians and vegans contains very little DHA, and very few vegetarian/vegan women in this study supplemented with DHA.

This study also found that breast milk from both vegetarian/vegan moms and omnivore moms was low in folate + folic acid, calcium, nicotinamide, and selenium. They said that requires follow-up in future studies.

The authors concluded, “The most important contribution of this study is the detailed and comprehensive description of micronutrients and lipids in human milk from omnivore milk donors and vegetarian/vegan women…Of particular concern is the lower DHA content in the milk of our vegetarian/vegan group. However, raising awareness and administering proper supplementation could bridge the gap, as has been the case with vitamin B12.”

What Can Vegan Moms Do?

This study emphasizes the importance of careful planning and supplementation during pregnancy and lactation if you are a vegetarian or vegan mom.

For example, the vegetarian/vegan women in this study were more likely to have low birthweight babies, and low birthweight infants are at risk for health issues later in life. That means:

Careful planning is required to select calorie- and protein-rich plant foods.

A high-quality plant protein supplement can be a great help.

Supplementation is particularly important during lactation to assure your breast milk adequately nourishes your newborn baby. For example, in this study:

The vitamin B12 level in the breast milk from vegetarian/vegan moms was adequate because 85% of them supplemented with vitamin B12.

The DHA level in the breast milk from vegetarian/vegan moms was inadequate because only 10% of them supplemented with DHA.

The authors of this study recommended that vegetarian and vegan moms consume at least 200 mg of DHA from algal sources while they are breastfeeding.

However, finding a prenatal supplement that provides all the nutrients you need prior to pregnancy, during pregnancy, and while breastfeeding is challenging. I gave you 7 tips for choosing the best prenatal supplements in a previous “Health Tips From the Professor” article.

The Bottom Line

A recent study asked whether the breast milk of vegetarian and vegan moms was sufficient for the needs of their newborn babies. The study found that:

Folate levels in their breast milk were sufficient because the diets of vegetarians and vegans contain many folate-rich foods.

Vitamin B12 levels in their breast milk were sufficient because 85% of the vegetarian and vegan women in this study supplemented with vitamin B12.

DHA levels in their breast milk were insufficient because the diets of vegetarian and vegan women are very low in DHA, and only 10% of the women in this study supplemented with DHA.

The authors of this study recommended that vegetarian and vegan moms consume at least 200 mg of DHA from algal sources while they are breastfeeding.

This study reinforces the need for supplementation during lactation to assure your breast milk adequately nourishes your newborn baby.

However, finding a prenatal supplement that provides all the nutrients you need prior to pregnancy, during pregnancy, and while breastfeeding is challenging. I gave you 7 tips for choosing the best prenatal supplement in a previous “Health Tips From the Professor” article.

For more information on this study read the article above.

These statements have not been evaluated by the Food and Drug Administration. This information is not intended to diagnose, treat, cure, or prevent any disease.

___________________________________________________________________________

For more detail about FTC regulations for health claims, see this link.

https://www.ftc.gov/business-guidance/resources/health-products-compliance-guidance

Does The Mediterranean Diet Improve Pregnancy Outcomes?

May 23, 2023 by Dr. Steve Chaney

Is The Mediterranean Diet Overrated?

Author: Dr. Stephen Chaney

You may have noticed that certain celebrities are singled out for fame and acclaim, while others of equal talent and accomplishment are virtually ignored.

The same thing occurs in the scientific realm. At present, the Mediterranean diet is the darling of the diet world. Study after study is designed to test the benefits of the Mediterranean diet while other excellent diets are ignored. I will discuss this phenomenon and ask whether the Mediterranean diet is overrated at the end of this article. But let’s start at the beginning.

Multiple studies have shown that the Mediterranean diet is associated with lower risk of heart disease, diabetes, and high blood pressure. Some studies suggest it is associated with lower risk of kidney disease and Alzheimer’s disease.

Studies also suggest that the Mediterranean diet is associated with an increase in lifespan (how long you live) and healthspan (how long you enjoy good health). In other words, these studies suggest that following a Mediterranean diet adds years to your life and life to your years.

Most of these studies have been done with men. However, there are enough studies with women to be confident that the beneficial effects of the Mediterranean diet on disease risk and lifespan apply to women as well as to men.

But what about pregnancy? Does the Mediterranean diet support a healthy pregnancy? Here the data are less clear. Three studies have been published showing that pregnant women who follow the Mediterranean diet are less likely to experience gestational diabetes (diabetes during pregnancy).

But what about other adverse pregnancy outcomes that can affect the health of both the mother and her baby such as:

Gestational hypertension (high blood pressure during pregnancy).
Preeclampsia (high blood pressure and protein in the urine that occurs late in pregnancy. It may be associated with liver and/or kidney damage).
Eclampsia (a severe form of preeclampsia where the mother also has seizures).
Preterm birth (birth prior to 37 weeks).
Low birth weight infant.

This study (N Makarem et al, JAMA Network Open. 5(12): e2248165, 2022) was designed to look at the effect of the Mediterranean diet on all seven of these adverse pregnancy outcomes.

How Was This Study Done?

The data for this analysis came from a large clinical trial called the Nulliparous Pregnancy (first time pregnancy) Outcomes Study. The study enrolled 7798 women in their first trimester of pregnancy from 8 medical centers across the country. The women were racially, ethnically, and geographically diverse.

Diet around the time of conception was assessed with a food frequency questionnaire administered at the mother’s first visit to the clinic (usually around 6-13 weeks after conception). The participants were asked to indicate their usual intake of 120 foods and beverages during the past 3 months. In other words, the participants were asked to indicate their diet prior to conception through early pregnancy.

Adherence to the Mediterranean diet was assessed using something called the aMed or Alternative Mediterranean Diet Score (a version of the Mediterranean diet that considers US food preferences). Each participant was assigned one point for:

Above average intake of vegetables, fruits, nuts, whole grains, legumes, fish, and the ratio of monounsaturated fat to saturated fat.

Below average intake of red meat and processed meats.

Alcohol intake was a bit more complicated:

Participants were given 1 point for one 12-ounce can of beer, 5 ounces of wine, or 1.5 ounces of liquor and 0 points for consumption above or below that amount.

The points for all these dietary components were added up to give an aMed score of 0-9, with 9 representing the best adherence to the Americanized version of the Mediterranean diet.

Does The Mediterranean Diet Improve Pregnancy Outcomes?

The authors started out by dividing the pregnant moms into thirds according to adherence to an Americanized Mediterranean diet based their aMed score. When they compared those in the top third (aMed scores of 6-9) with those in the lowest third (aMed scores of 0-3) the risk of developing:

Any adverse pregnancy outcome was reduced by 21%.

Preeclampsia or eclampsia were reduced by 28%.

Gestational diabetes was reduced by 37%.

Other adverse pregnancy outcomes were not statistically different.

Next, they asked whether stricter adherence to the Mediterranean diet would be even more beneficial. To do this they divided the pregnant moms into fifths. When they compared those in the top fifth (aMed scores of 7-9) with those in the lowest fifth (aMed scores of 0-2) the risk of developing:

Any adverse pregnancy outcome was still reduced by 20%, but…

- Preeclampsia and eclampsia were reduced by 35%.

- Gestational diabetes was reduced by 54%.

- Other adverse pregnancy outcomes were not statistically different.

When they broke the results down into participant subgroups:

The effect of the Mediterranean diet on any adverse pregnancy outcomes was not affected by prepregnancy BMI (a measure of obesity), race, or ethnicity.

However, it was significantly affected by age. Any adverse pregnancy outcome was reduced by:

- 48% in women over 35.

- 15% in women younger than 35.

The authors concluded, “We demonstrate that a Mediterranean diet pattern is associated with lower risk of developing any APO [adverse pregnancy outcome] and multiple individual APOs in US women…Our findings add to the growing body of evidence that the Mediterranean diet pattern may play an important role in preserving the health of women across the lifespan, including during pregnancy.”

Is The Mediterranean Diet Overrated?

At the beginning of this article, I posed the question, “Is the Mediterranean diet overrated?” When the authors broke the results down by food group, it suggested the answer may be, “Yes”.

The reduction in any adverse pregnancy outcome was associated with:

Above average consumption of vegetables, fruits, legumes, and fish.

The reduction in preeclampsia and eclampsia was associated with:

Above average consumption of vegetables, fruits, and fish.

The reduction in gestational diabetes was associated with:

Above average consumption of vegetables, and…

Below average consumption of red meat and processed meats.

If you are saying to yourself, “Wait a minute. Doesn’t this pattern of food consumption describe almost any whole food, primarily plant-based diet”, you would be correct. In theory, this pattern of food consumption is also consistent with the DASH diet, Mind diet, Scandinavian diet, flexitarian diet, pesco-vegetarian diet, and semi vegetarian diet, just to name a few.

In my opinion there is nothing about this study that restricts beneficial pregnancy outcomes to the Mediterranean diet. However, I do have a few caveats about that statement.

A good prenatal supplement is a good idea to make sure you are getting the vitamins and minerals required for a successful pregnancy. However, as I have described in a previous article finding a good prenatal supplement may not be as easy as it should be.

Choline is important for a healthy pregnancy, and it is missing in many prenatal supplements. While choline is found in many plant foods, the best sources of choline are fish, poultry, eggs, and dairy. You want to be sure to include some of these in your diet and/or look for a prenatal supplement containing at least 200 mg of choline.

The long chain omega-3s DHA and EPA are important for a healthy pregnancy and are also missing or present in inadequate amounts in many prenatal supplements.

The best dietary sources of DHA and EPA are cold water fish like salmon, tuna, sardines, and herring. That means:

- If you are following the DASH diet or something similar, you will want to substitute fish for red meat.

- A pesco-vegetarian diet is probably a better choice for you than a semi-vegetarian because it focuses on fish as the main protein source in place of poultry and red meat.

- If you are not a big fish lover, you should consider an omega-3 supplement supplying at least 250 mg of long chain omega-3s with most of it as DHA.

What Does This Study Mean For You?

Let me close by putting a few things into perspective.

1) When I said that the Mediterranean diet may be overrated, I did not mean it wasn’t an excellent diet. I simply mean it is probably not any better than other whole food, primarily plant-based diets (with the caveats I listed above).

2) The pregnancy benefits of the Mediterranean diet (and other healthy diets) are related to the overall health of the mother. A good prenatal supplement is still important to assure adequate amounts of all the nutrients essential for a healthy pregnancy.

For example, the authors pointed out that most women do not change their dietary habits when they become pregnant, and that their pregnancy is more likely to be successful if they are in good health at the time of conception.

3) Most diets of women of childbearing age do not provide adequate amounts of choline and omega-3s, so it is important to choose a prenatal supplement program that provides adequate amounts of choline and omega-3s.

4) Adequate calories and protein are also important for a healthy pregnancy.

Pregnancy is not the time to lose weight, even if you are overweight.

A vegan diet may not provide enough protein unless it has been designed by a dietitian.

You should discuss your current diet with your health care provider, and they may refer you to a dietitian if necessary.

The Bottom Line

The Mediterranean Diet is currently the darling of the nutrition world. Yes, numerous studies have shown that people consuming the Mediterranean diet are healthier and live longer. But we find ourselves in a situation where study after study is being designed to look for other benefits of the Mediterranean diet while equally healthy diets are being ignored.

The study discussed in this article is a perfect example. It was designed to determine whether adherence to the Mediterranean diet prior to and during pregnancy reduced the risk of experiencing adverse outcomes during pregnancy – outcomes that could affect the health of the mother and her baby.

The answer to that question was, “Yes”. Adherence to the Mediterranean diet reduced the risk of:

Any adverse outcome during pregnancy by 20%.

Preeclampsia and eclampsia by 35%.

Gestational diabetes by 54%.

And the risk reduction was even greater for women over 35.

However, when the investigators looked at the foods responsible for the reduction in adverse pregnancy outcomes, it appears likely that any whole food, primarily plant-based diet would provide the same results.

In short, this study showed that adherence to the Mediterranean diet improves pregnancy outcomes. The authors chose to focus on the Mediterranean diet because of its popularity. But their data show it is likely that other whole food, primarily plant-based diets would be equally beneficial.

For more information on this study and what it means for you, read the article above.

These statements have not been evaluated by the Food and Drug Administration. This information is not intended to diagnose, treat, cure, or prevent any disease.

___________________________________________________________________________

For more detail about FTC regulations for health claims, see this link.

https://www.ftc.gov/business-guidance/resources/health-products-compliance-guidance

Is Your Prenatal Supplement Adequate?

November 8, 2022 by Dr. Steve Chaney

What Should You Look For In A Prenatal Supplement?

Author: Dr. Stephen Chaney

You want to do the best for your unborn child. So, you try to find the best prenatal supplement. You may ask your doctor to recommend a prenatal supplement. You may ask your best friend what supplement she used when she was pregnant. Or perhaps you scan online reviews of prenatal supplements by random dietitians or nutrition gurus to select the “best” prenatal supplements.

Then you read the supplement label or the company’s website and see claims like:

“Supports optimal nutrition before, during, and after pregnancy”

“Packed with 16 nutrients to support fetal development, immunity, energy metabolism, and more”

“Concise prenatal formula supports both bone and brain development”

It sounds so good. You think you have found the perfect prenatal supplement. “Right?”

Perhaps not. A recent study (JB Adams et al, Maternal Health, Neonatology, and Perinatology, 8:4, 2022) did an in-depth review of prenatal supplement recommendations and how well prenatal supplements on the market met those recommendations.

The results were not encouraging. The authors concluded, “[Our] analysis found that prenatal supplements vary widely in content, often only contain a subset of essential vitamins, and the levels were often below…recommendations.”

In other words, their study found that most prenatal vitamins may not be adequate to support your needs and the needs of your child through pregnancy and breastfeeding.

I know this is likely to be a topic of great concern for many of you. So, I will examine the study in detail and give you some guidelines for selecting the perfect prenatal supplement.

How Was This Study Done?

This study can be divided into two parts.

#1: What Should The Ideal Prenatal Supplement Contain:

The authors started off by reevaluating the optimal recommendations for prenatal supplements. They reviewed over 200 articles, focusing on articles that:

Provided insight into optimal dosage [of essential nutrients] such as treatment studies on the effects of different doses on outcomes and biomarkers.

Were larger, more rigorously designed, such as randomized double-blind placebo-controlled studies.

The studies included in their review fell into three categories:

The association of low levels of vitamins with health problems [during pregnancy and in the child after birth].

2) Studies on the changes in [blood] vitamin levels during pregnancy [when the mother is either] un-supplemented or supplemented (The blood level of many vitamins decreases dramatically during pregnancy without supplementation).

3) Clinical trials on the effect of vitamin supplementation on health problems [during pregnancy].

They used these data to create their recommendations for what an ideal prenatal supplement should contain. In some cases, their recommendations were higher than current RDA recommendations for pregnant women.

#2: How Do Currently Available Prenatal Supplements Compare With Their Recommendations For The Ideal Supplement?

For this part of the study, they created a comprehensive list of the nutrients provided by 188 prenatal supplements currently on the market using databases created by the National Institutes of Health. Where these databases were outdated, the nutrient list for that supplement was updated using information on the manufacturer’s websites or labels on retail websites such as Amazon.

Finally, they compared the nutrient content of all 188 prenatal supplements with their recommendations for the ideal prenatal supplement.

Is Your Prenatal Supplement Adequate?

There are four points I wish to make before I review the results of this study.

I suspect you are most interested in finding out how prenatal supplements on the market compare with their recommendations for an ideal supplement, so that is what I will discuss below.

2) As I mentioned above, some of their recommendations exceed the current Daily Value (DV) recommendations for pregnant and lactating women. I will point that out whenever it significantly affects the comparisons.

3) The authors of this article made the point that most women going on a prenatal supplement will probably discontinue taking their multivitamin supplement. Thus, their recommendations included nutrients commonly included in multivitamin supplements. This is a valid point, and something you should consider when choosing a prenatal supplement. However, in my discussion below I will focus on the nutrients that are universally recognized as important for pregnancy and lactation.

4) The authors focused on prenatal supplements that had less than the recommended amount of essential nutrients. They did not ask how many of those supplements had excessive amounts of certain nutrients. In my non-systematic review of prenatal supplements, I found several that had doses of some nutrients in thousands of percent of the DV recommendations. In my opinion, this is potentially unsafe for pregnancy and nursing. I will cover this topic in more detail in my discussion.

With that in mind, here are the results of their review.

Vitamins:

When you look at vitamins that have long been recognized as essential for pregnant women, the results are encouraging:

Vitamin D, folate, vitamin B12, and vitamin B6 are found in adequate amounts compared to the DV in most prenatal supplements.

However, when you look at nutrients that have more recently been recognized as essential for pregnant women, the story is very different:

For vitamin K only 31% of prenatal supplements contain vitamin K and only 16% meet or exceed their recommendation for vitamin K.

- Their recommendation (90 mcg/day) is identical to the DV for vitamin K. So, there is no doubt that most prenatal supplements do not provide adequate amounts of vitamin K.

For choline only 40 % of prenatal supplements contain choline and only 2% meet or exceed their recommendation for choline.

- Their recommendation (350 mg/day) for choline is less than the 450 mg/day recommended by the NIH and the American College of Obstetricians and Gynecologists.

- The average prenatal supplement only provides 25 mg of choline, which is wildly inadequate by any standard.

For DHA only 42% of prenatal supplements contain DHA and only 1% meet or exceed their recommendation for DHA.

- Their recommendation (600 mg/day) for DHA is higher than the 200 – 300 mg/day recommended by the most health organizations.

- However, the average prenatal supplement only provides 94 mg of DHA, so even at 200 – 300 mg/day a substantial percentage of prenatal supplements do not provide adequate amounts of DHA.

Minerals:

This study did not consider minerals, so I will draw on another source to estimate the adequacy of minerals in prenatal supplements.

Three key minerals for a healthy pregnancy are iron, calcium, and iodine (Yes, I realize that iodine is not a mineral, but it is usually listed with the minerals on supplement labels. And it is also essential for a healthy pregnancy). Fortunately, another recent study (LG Saldanha et al, Journal of the American Academy of Dietetics, 117: 1429-1436, 2017) looked at the adequacy of these nutrients in 214 prenatal supplements. This study found:

The iron DV for pregnant and lactating women is 27 mg/day and 95% of prenatal supplements contained iron at the recommended level.

The calcium DV for pregnant and lactating women is 1,300 mg/day. A high percentage (91%) of prenatal supplements contain calcium, but many prenatal supplements only provide 100-200 mg of calcium. That is far less than the DV.

The situation for iodine is even more alarming. Only 50% of prenatal supplements contain iodine. And for those that do contain iodine, the average iodine content is only 150 mcg (The DV for pregnant and lactating women is 290 mcg/day).

It is no wonder the authors of these two studies concluded that most prenatal supplements on the market do not provide adequate amounts of all the nutrients needed for a healthy pregnancy. The shortfalls are particularly acute for vitamin K, choline, DHA, iodine, and calcium.

What Should You Look For In A Prenatal Supplement?

By now you are probably wondering how you know a good prenatal supplement from a bad one. Here are six simple rules for choosing the ideal prenatal supplement.

Don’t rely on health “gurus” to choose your prenatal supplement for you. I did a little “sleuthing” for you. I searched the internet for websites claiming to have identified the “best” prenatal supplements. I checked out the supplements they recommended, and here is what I found:

The supplements the gurus recommended checked all the boxes in that they had some of all the nutrients required for a healthy pregnancy.

However, the amount of those nutrients ranged from lows of 10-20% of the DV for pregnant and lactating women to thousands of percent of the DV for others.

In other words, they contained grossly inadequate levels of some nutrients and potentially toxic levels of others.

2) Don’t believe label claims or claims made on the manufacturer’s website. Remember the claim, “Concise prenatal formula supports both bone and brain development”, that I mentioned at the beginning of this article? The supplement associated with that claim had only 100 mg of calcium and no DHA. It is hard to imagine a supplement like that supporting either bone or brain health. The claim was bogus.

3) Don’t assume your doctor’s recommendation is the ideal prenatal supplement. A recent study (LG Saldanha et al, Journal of the American Academy of Dietetics, 117: 1429-1436, 2017) compared prescription (the kind your doctor is likely to prescribe) and non-prescription prenatal supplements. It found:

Compared with non-prescription supplements, prescription supplements contained significantly fewer vitamins (9 versus 11) and minerals (4 versus 8).

While prescription supplements contained more folic acid than non-prescription supplements, they contained significantly less vitamin A, vitamin D, iodine, and calcium.

4) Look for a prenatal supplement containing all the essential nutrients, not just those important for a healthy pregnancy. The authors of the first study made the point that most women will stop taking their regular multivitamin when they start their prenatal supplement. If that is you, your prenatal supplement should contain the nutrients you were getting from your multivitamin.

5) Look for a prenatal supplement that provide 100% of DV for all nutrients except the bulky ones. The ideal prenatal supplement should contain 100% of the DV for pregnant and lactating women for all essential nutrients. Avoid supplements with very low amounts of some nutrients and large excesses of others.

Bulky nutrients like calcium, magnesium, and choline are exceptions. It would be hard to get 100% DV for those nutrients in any supplement you could swallow.

6) Look for a prenatal supplement that “fills the gap” for bulky nutrients.

Fortunately, the NIH has estimated how much of these nutrients the average American woman gets in her diet. That allows us to estimate how much the average woman needs to get from her prenatal supplement to bring her total intake up to the DV for pregnant and lactating women. That amounts to 458 mg for calcium, 166 mg for magnesium, and 272 mg for choline.

- That gives you a reasonable benchmark for assessing whether a prenatal supplement is providing enough of those important nutrients. When you read their labels, you will find most prenatal supplements are woefully inadequate for these nutrients.

- You also need to ask whether your diet is “average”. For example, the average American gets 72% of their calcium from dairy foods. If you do not consume dairy, you may need to get more calcium from your supplement.

7) Avoid the excesses. Your unborn baby is precious. You don’t want to expose it to potentially toxic doses of vitamins or minerals. Avoid any prenatal supplement containing thousands of percent of the DV for some nutrients. And I would recommend caution with supplements containing over 200% of the DV for some nutrients if you are taking other supplements that may provide the same nutrient(s).

The Bottom Line

Two recent studies have surveyed hundreds of prenatal vitamins and asked whether they provided adequate amounts of the nutrients that are essential for a healthy pregnancy. The results were shocking.

While most prenatal supplements provided adequate amounts of folic acid, vitamin B12, vitamin B6, vitamin D, and iron…

They were woefully inadequate for vitamin K, calcium, choline, iodine, and DHA – all nutrients that are essential for a healthy pregnancy.

Furthermore, prescription prenatal supplements (the kind your doctor is likely to prescribe) were no better than non-prescription supplements.

The authors of the first study concluded, “[Our] analysis found that prenatal supplements vary widely in content, often only contain a subset of essential vitamins, and the levels were often below…recommendations.”

In other words, their study found that most prenatal vitamins on the market may not be adequate to support your needs and the needs of your child through pregnancy and breastfeeding.

For more details on this study and my discussion of how you can select the ideal prenatal supplement for you and your unborn child, read the article above.

These statements have not been evaluated by the Food and Drug Administration. This information is not intended to diagnose, treat, cure, or prevent any disease

Vitamin D And ADHD

August 2, 2022 by Dr. Steve Chaney

Can ADHD Be Prevented?

Author: Dr. Stephen Chaney

If you are pregnant, or of childbearing age, should you be supplementing with vitamin D? Increasingly, the answer appears to be yes.

Based on blood 25-hydroxy vitamin D levels (considered the most accurate marker of vitamin D status):

- 8-11% of pregnant women in the US are deficient in vitamin D (<30 nmol/L).

- 25% of pregnant women have insufficient vitamin D status (30-49 nmol/L).

In short, that means around 1/3 of pregnant women in the US have insufficient or deficient levels of vitamin D. The effect of inadequate vitamin D during pregnancy is not just an academic question.

2) The Cochrane Collaboration (considered the gold standard for evidence-based medicine) has recently concluded that supplementation with vitamin D reduces the risk of significant complications during pregnancy.

3) Another recent study found that inadequate vitamin D status during pregnancy delayed several neurodevelopmental milestones in early childhood, including gross motor skills, fine motor skills, and social development.

If neurodevelopmental milestones are affected, what about ADHD? Here the evidence is not as clear. Some studies have concluded that vitamin D deficiency during pregnancy increases the risk of ADHD in the offspring. Other studies have concluded there is no effect of vitamin D deficiency on ADHD.

Why the discrepancy between studies?

Most of the previous studies have been small. Simply put, there were too few children in the study to make statistically reliable conclusions.
Most of the studies measured maternal 25-hydroxyvitamin D levels in the third trimester or in chord blood at birth. However, it is during early pregnancy that critical steps in the development of the nervous system take place.

Thus, there is a critical need for larger studies that measure maternal vitamin D status in the first trimester of pregnancy. This study (M Sucksdorff et al, Journal of the American Academy of Child & Adolescent Psychiatry, 60: 142-151, 2021) was designed to fill that need.

How Was The Study Done?

This study compared 1,067 Finnish children born between 1998 and 1999 who were subsequently diagnosed with ADHD and 1,067 matched controls without ADHD. There were several reasons for choosing this experimental group.

Finland is among the northernmost European countries, so sun exposure during the winter is significantly less than for the United States and most other European countries. This time period also preceded the universal supplementation with vitamin D for pregnant women that was instituted in 2004.

Consequently, maternal 25-hydroxyvitamin D levels were significantly lower than in most other countries. This means that a significant percentage of pregnant women were deficient in vitamin D, something not seen in most other studies. For example:

49% of pregnant women in Finland were deficient in vitamin D (25-hydoxyvitamin D <30 nmol/L) compared to 8-11% in the United States.

33% of pregnant women in Finland had insufficient vitamin D status (25-hydroxyvitamin D 30-49.9 nmol/L) compared to 25% in the United States.

Finland, like many European countries, keeps detailed health records on its citizens. For example:

- The Finnish Prenatal Study collected data, including maternal 25-hydroxyvitamin D levels during the first trimester), for all live births between 1991 and 2005.

- The Care Register for Health Care recorded, among other things, all diagnoses of ADHD through 2011.

Thus, this study avoided the limitations of earlier studies. It was ideally positioned to compare maternal 25-hydroxyvitamin D levels during the first trimester of pregnancy with a subsequent diagnosis of ADHD in the offspring. The long-term follow-up was important to this study because the average age of ADHD diagnosis was 7 years (range = 2-14 years).

Vitamin D And ADHD

Does maternal vitamin D affect ADHD in the offspring? The answer to this question appears to be a clear, yes.

If you divide maternal vitamin D levels into quintiles:

Offspring of mothers in the lowest vitamin D quintile (25-hydroxyvitamin D of 7.5-21.9 nmol/L) were 53% more likely to develop ADHD than offspring of mothers in the highest vitamin D quintile (49.5-132.5 nmol/L).

When you divide maternal vitamin D levels by the standard designations of deficient (<30 nmol/L), insufficient (30-49.9 nmol/L), and sufficient (≥50 nmol/L):

Offspring of mothers who were deficient in vitamin D were 34% more likely to develop ADHD than children of mothers with sufficient vitamin D status.

The authors concluded: “This is the first population-based study to demonstrate an association between low maternal vitamin D during the first trimester of pregnancy and an elevated risk for ADHD diagnosis in offspring. If these findings are replicated, they may have public health implications for vitamin D supplementation and perhaps changing lifestyle behaviors during pregnancy to ensure optimal maternal vitamin D levels.”

Can ADHD Be Prevented?

I realize that this is an emotionally charged title. If you have a child with ADHD, the last thing I want is for you to feel guilty about something you may not have done. So, let me start by acknowledging that there are genetic and environmental risk factors for ADHD that you cannot control. That means you could have done everything right during pregnancy and still have a child who develops ADHD.

Having said that, let’s examine things that can be done to reduce the risk of giving birth to a child who will develop ADHD, starting with vitamin D. There are two aspects of this study that are important to keep in mind.

#1: The increased risk of giving birth to a child who develops ADHD was only seen for women who were vitamin D deficient. While vitamin D deficiency is only found in 8-11% of pregnant mothers in the United States, that is an average number. It is more useful to ask who is most likely to be vitamin D deficient in this country. For example:

Fatty fish and vitamin D-fortified dairy products are the most important food sources of vitamin D. Fatty fish are not everyone’s favorite and may be too expensive for those on a tight budget. Many people are lactose intolerant or avoid milk for other reasons. If you are not eating these foods, you may not be getting enough vitamin D from your diet. This is particularly true for vegans.

If you have darker colored skin, you may have trouble making enough vitamin D from sunlight. If you are also lactose intolerant, you are in double trouble with respect to vitamin D sufficiency.

Obesity affects the distribution of vitamin D in the body. So, if you are overweight, you may have low 25-hydroxyvitamin D levels in your blood.

The vitamin D RDA for pregnant and lactating women is 600 IU, but many multivitamin and prenatal supplements only provide 400 IU. If you are pregnant or of childbearing age, it is a good idea to look for a multivitamin or prenatal supplement that provides at least 600 IU, especially if you are in one of the high risk groups listed above.

Some experts recommend 2,000 to 4,000 IU of supplemental vitamin D. I would not recommend exceeding that amount without discussing it with your health care provider first.

Finally, for reasons we do not understand, some people have a difficult time converting vitamin D to the active 25-hydroxyvitamin D and 1,25-dihydroxyvitamin D in their bodies. If you are pregnant or of childbearing age, it is a good idea to have your blood 25-hydroxyvitamin D levels determined and discuss with your health care provider how much vitamin D you should be taking. Many people need more than 600 IU to reach vitamin D sufficiency status.

#2: Maternal vitamin D deficiency has a relatively small effect (34%) on the risk of the offspring developing ADHD. That means assuring adequate vitamin D status during pregnancy should be part of a holistic approach for reducing ADHD risk. Other factors to consider are:

Low maternal folate and omega-3 status.

Smoking, drug, and alcohol use.

Obesity.

Sodas and highly processed foods.

Alone, each of these factors has a small and uncertain influence on the risk of your child developing ADHD. Together, they may play a significant role in determining your child’s risk of developing ADHD.

In closing, there are three take-home lessons I want to leave you with:

The first is that there is no “magic bullet”. There is no single action you can take during pregnancy that will dramatically reduce your risk of giving birth to a child who will develop ADHD. Improving your vitamin D, folate, and omega-3 status; avoiding cigarettes, drugs, and alcohol; achieving a healthy weight; and eating a healthy diet are all part of a holistic approach for reducing the risk of your child developing ADHD.

2) The second is that we should not think of these actions solely in terms of reducing ADHD risk. Each of these actions will lead to a healthier pregnancy and a healthier child in many other ways.

3) Finally, if you have a child with ADHD and would like to reduce the symptoms without drugs, I recommend this article.

The Bottom Line

A recent study looked at the correlation between maternal vitamin D status during the first trimester of pregnancy and the risk of ADHD in the offspring. The study found:

Offspring of mothers who were deficient in vitamin D were 34% more likely to develop ADHD than children of mothers with sufficient vitamin D status.

In the article above I discuss what this study means for you and other factors that increase the risk of giving birth to a child who will develop ADHD.

For more details read the article above.

These statements have not been evaluated by the Food and Drug Administration. This information is not intended to diagnose, treat, cure, or prevent any disease.

The Perils Of Iodine Deficiency For Women

May 10, 2022 by Dr. Steve Chaney

Where Can You Get The Iodine You Need?

Author: Dr. Stephen Chaney

It shouldn’t be happening. The introduction of iodized salt in the 1920s virtually eliminated iodine deficiency in this country. However, in just the past twenty years the incidence of iodine deficiency has increased 3-8-fold in women of childbearing age. Recent studies have estimated that today 30-40% of women of childbearing age are iodine deficient.

How did that happen?

We have been told to cut back on sodium. Many Americans have responded by throwing away the (iodized) salt shaker. Unfortunately, we still get a lot of salt from processed foods, and that salt is usually non-iodized.

When we do add salt to our foods it is usually the “healthier” designer salts. First it was sea salt. Now it is trendy versions like Pink Himalayan Salt. While sea salt might have some iodine naturally, the trendier versions are non-iodized.

The New-Age Whole Food diets often ban salt from the diet. That increases the probability of becoming iodine deficient. For example, a recent study reported that women who followed the Paleo diet for two years became iodine deficient (S. Manousi et al, European Journal of Clinical Nutrition, 72: 124-129, 2018).

The consequences of iodine deficiency, especially among women of childbearing age, are alarming. In a previous issue of “Health Tips From the Professor” I reported that iodine is essential for bone and neural development during fetal development and infancy.

This study (JL Mills et al, Human Reproduction, doi: 10.1093/humrep/dex379, 2018) reports that iodine deficiency also reduces a woman’s chances of becoming pregnant.

How Was The Study Done?

This study recruited 501 couples (ages 18-40) from 16 counties in Michigan and Texas. The women had all discontinued conception within the previous two months with the intention of becoming pregnant and were followed for an additional 12 months. Women with known thyroid disease were excluded from the study.

Urine samples were collected from each woman at the beginning of the study to determine iodine and creatine levels. The women used fertility monitors to time intercourse relative to ovulation (Basically, that means they optimized their chances of becoming pregnant). They then used digital home pregnancy monitors on the day of expected menstruation to identify pregnancies.

Finally, 90% of the women took either a multivitamin or a prenatal vitamin during the study (The significance of this will be discussed later).

The Perils Of Iodine Deficiency For Women

The results of the study were:

44.3% of the women in the study were iodine deficient (defined as iodine-creatine ratios of <100 mcg/g). This was further broken down to:

- 21.8% were mildly iodine deficient (50-99 mcg/g).

- 20.8% were moderately iodine deficient (20-49 mcg/g).

- 1.7% were severely iodine deficient (<20 mcg/g).

That is a total of 22.5% who had moderate to severe iodine deficiency.

Women who had moderate to severe iodine deficiency had a 46% decrease in the chance of becoming pregnant over each menstrual cycle compared to the iodine sufficient group.

A simple way of reporting those data would be to say that their chances of becoming pregnant were reduced by 46%, but that would not convey the whole picture. Most of the women did become pregnant during the 12-month study. However, it took the women with moderate to severe iodine deficiency twice as long to become pregnant. Iodine deficiency did not prevent pregnancy from occurring, but it delayed it.

The authors concluded: “In summary, our data show that groups of women with iodine concentrations in the moderate to severe deficient range experience a significantly longer time to pregnancy…The US and European countries where iodine deficiency is common should evaluate the need for programs to increase iodine intake for women of childbearing age, particularly those trying to become pregnant.”

And the increased difficulty in becoming pregnant is just the tip of the iceberg. As I mentioned above, the consequences of iodine deficiency among women of childbearing age, can be devastating.

Iodine is essential for bone and neural development during fetal development and infancy. The American Academy of Pediatrics, The National Institutes Of Health, and the World Health Organization have all declared that mild iodine deficiency during pregnancy can prevent normal cognitive development and reduce IQ levels in children.

Because the consequences of iodine deficiency during pregnancy are so detrimental, if iodine deficiency also reduced the chances of a woman becoming pregnant, it could be considered a good thing. It could be part of Nature’s Plan. Unfortunately, this study suggests that iodine deficiency only delays pregnancy. It doesn’t prevent it.

Where Can You Get The Iodine You Need?

Since iodine is so essential for a healthy pregnancy, the important question becomes: “Where can you get the iodine you need?”

You could start by using old-fashioned iodized salt rather than designer salts in your salt shaker. However, I am reluctant to recommend anything that would increase sodium intake. We get far too much from processed foods already.

Seafood (or seaweed, if you are a vegetarian) are the best food sources of iodine. However, our oceans are so contaminated I would recommend consuming those foods only occasionally.

You will often see bread and dairy mentioned as good food sources because iodine was used in the preparation of those foods. However, iodine has largely been replaced by other agents, so those foods should no longer be considered good sources. For example:

- Iodine in commercial breads has traditionally come from the use of iodate as a dough conditioner. Today iodate has largely been replaced with bromide in commercial bread making. Not only does this trend decrease the amount of iodine available in our diet, but bromide also interferes with iodine utilization in our bodies

- Iodine in milk has traditionally come from the use of iodine-containing disinfectants to clean milk cans and teats. However, they have largely been replaced with other disinfectants

Fruits and vegetables are a variable source of iodine, depending on where they were grown. That is because iodine levels in the soils vary tremendously from region to region.

That leaves multivitamins and prenatal vitamins as your best source. However, you do need to read labels. You should look for supplements that provide 150 mcg of iodine. Unfortunately, only 50% of prenatal supplements in the United States even contain iodine. Remember, 90% of the women in this study took either a multivitamin or prenatal supplement and 44.3% of them were iodine deficient.

The Bottom Line

The introduction of iodized salt in the 1920s virtually eliminated iodine deficiency in this country. Now, almost 100 years later, iodine deficiency is back. Recent studies estimate that 30-40% of women of childbearing age are iodine deficient. This is concerning. Previous studies have shown iodine deficiency affects mental development during fetal development and infancy. A recent study suggests that iodine deficiency may also make it more difficult for women to become pregnant. Specifically, the study reported:

44.3% of the women in the study were iodine deficient. This was further broken down to:

- 21.8% were mildly iodine deficient.

- 20.8% were moderately iodine deficient.

- 1.7% were severely iodine deficient.

That is a total of 22.5% with moderate to severe iodine deficiency.

Women who had moderate to severe iodine deficiency had a 46% decrease in their chance of becoming pregnant over each menstrual cycle compared to the iodine sufficient group.

For more details about why iodine deficiency has reemerged in this country and where we can get the iodine we need, read the article above.

These statements have not been evaluated by the Food and Drug Administration. This information is not intended to diagnose, treat, cure or prevent any disease.

How Much Omega-3 Should You Take During Pregnancy?

June 22, 2021 by Dr. Steve Chaney

Which Omega-3s Are Beneficial?

Author: Dr. Stephen Chaney

Preterm births (births occurring before 37 weeks) are increasing in this country. Just between 2018 and 2019, the percentage of preterm births increased by 2% to over 10% of all pregnancies. That is a concern because preterm births are associated with an increased risk of:

Visual impairment.
Developmental delays.
Learning difficulties.
Problems with normal development of lungs, eyes, and other organs.

Plus, it is expensive to keep premature babies alive. One recent study estimated that reducing the incidence of preterm births by around 50% could reduce health care costs by $6 billion in the United Stated alone.

Of the 10% preterm births, 2.75% of them are early preterm births (births occurring before 34 weeks). Obviously, the risk of health problems and the cost of keeping them alive is greatest for early preterm babies.

We don’t know why preterm births are increasing, but some experts feel it is because in this country:

More older women are having babies.

There is increased use of fertility drugs, resulting in multiple babies

Unfortunately, there is no medical standard for identifying pregnancies at risk for preterm birth. Nor is there any agreement around prevention measures for preterm births.

However, recent research has suggested that some premature births may be caused by inadequate omega-3 status in the mother and can be prevented by omega-3 supplementation.

What Do We Know About Omega-3s And Risk Of Preterm Births?

The role of omega-3s on a healthy pregnancy has been in the news for some time. Claims have been made that omega-3s reduce preterm births, postnatal depression, and improve cognition, IQ, vision, mental focus, language, and behavior in the newborn as they grow.

The problem is that almost all these claims have been called into question by other studies. If you are pregnant or thinking of becoming pregnant, you don’t know what to believe.

Fortunately, a group called the Cochrane Collaboration has recently reviewed these studies. The Cochrane Collaboration consists of 30,000 volunteer scientific experts from across the globe whose sole mission is to analyze the scientific literature and publish reviews of health claims so that health professionals, patients, and policy makers can make evidence-based choices about health interventions. Their reviews are considered the gold standard of evidence-based medicine.

This is because most published meta-analyses simply report “statistically significant” conclusions. However, statistics can be misleading. As Mark Twain said: “There are lies. There are damn lies. And then there are statistics”.

The problem is the authors of most meta-analyses group studies together without considering the quality of studies included in their analysis. This creates a “Garbage In – Garbage Out” effect. If the quality of individual studies is low, the quality of the meta-analysis will also be low.

The Cochrane Collaboration reviews are different. They also report statistically significant conclusions from their meta-analyses. However, they carefully consider the quality of each individual study in their analysis. They look at possible sources of bias. They look at the design and size of the studies. Finally, they ask whether the conclusions are consistent from one study to the next. They clearly define the quality of evidence that backs up each of their conclusions.

For omega-3s and pregnancy, the Cochrane Collaboration performed a meta-analysis and review of 70 randomized controlled trials that compared the effect of added omega-3s on pregnancy outcomes with the effect of either a placebo or no omega-3s. These trials included almost 19,927 pregnant women.

This Cochrane Collaboration Review looked at all the claims for omega-3s and pregnancy outcome, but they concluded that only two of the claims were supported by high-quality evidence:

Omega-3s reduce the risk of preterm births.

Omega-3s reduce the risk of low birth-weight infants.

The authors concluded: “Omega-3 supplementation during pregnancy is an effective strategy for reducing the risk of preterm birth…More studies comparing [the effect of] omega-3s and placebo [on preterm births] are not needed at this point.”

In other words, they are saying this conclusion is definite. The Cochrane Collaboration has declared that omega-3 supplementation should become part of the standard of medical care for pregnant women.

However, the Cochrane Collaboration did say that further studies were needed “…to establish if, and how, outcomes vary by different types of omega-3s, timing [stage of pregnancy], doses [of omega-3s], or by characteristics of women.”

That’s because these variables were not analyzed in this study. The study included clinical trials:

Of women at low, moderate, and high risk of poor pregnancy outcomes.

With DHA alone, with EPA alone, and with a mixture of both.

Omega-3 doses that were low (˂ 500 mg/day), moderate (500-1,000 mg/day), and high (> 1,000 mg/day).

I have discussed these findings in more detail in a previous issue of “Health Tips From The Professor”

How Was This Study Done?

The current study (SE Carlson et al, EClinicalMedicine, 2021) is a first step towards answering those questions.

The authors of this study focused on how much DHA supplementation is optimal during pregnancy. This is an important question because there is currently great uncertainty about how much DHA is optimal:

The American College of Obstetrics and Gynecology recommends supplementation with 200 mg/day of DHA. However, that recommendation assumes that the increase will come from fish and was influenced by concerns that omega-3-rich fish are highly contaminated with heavy metals and PCBs.

Another group of experts was recently asked to develop guidelines for omega-3 supplementation during pregnancy. They recommended pregnant women consume at least 300 mg/day of DHA and 220 mg/day of EPA.

The WHO has recommended of minimum dose of 1,000 mg of DHA during pregnancy.

Many prenatal supplements now contain 200 mg of DHA, but very few provide more than 200 mg.

Accordingly, the authors took the highest and lowest recommendations for DHA supplementation and asked whether 1,000 mg of DHA per day was more effective than 200 mg of DHA at reducing the risk of early preterm births. Their hypothesis was that 1,000 mg of DHA would be more effective than 200 mg/day at preventing early preterm births.

This study was a multicenter, double-blind, randomized trial of 1032 women recruited at one of three large academic medical centers in the United States (University of Kansa, Ohio State University, and University of Cincinnati).

The women were ≥ 18 years old (average age = 30) and between 12 and 20 weeks of gestation when they entered the study.

The breakdown by ethnicity was 50% White, 22% Black or African American, 22% Hispanic, 6% Other.

18% had a prior preterm birth (<37 weeks) and 7% had a prior early preterm birth (<34 weeks).

Prior to enrollment in the study 47% of the participants reported taking a DHA supplement and 19% of the participants took a DHA supplement with > 200 mg/day.

All the participants received 200 mg DHA capsules and were told to take one capsule daily. The participants were also randomly assigned to take 2 additional capsules that contained a mixture of corn and soybean oil (the 200 mg DHA/day group) or 2 capsules that contained 400 mg of DHA (the 1,000 mg DHA/day group). The capsules were orange flavored so the participants could not distinguish between the DHA capsules and the placebo capsules.

Blood samples were drawn upon entry to the study and either just prior to delivery or the day after delivery to determine maternal DHA status.

The study was designed to look at the effect of DHA dose (1,000 mg or 200 mg) on early preterm birth (<34 weeks), preterm birth (<37 weeks), low birth weight (< 3 pounds), and several other parameters related to maternal and neonatal health.

How Much Omega-3 Should You Take During Pregnancy?

The primary findings from this study were:

The rate of early preterm births (<34 weeks) was less (1.7%) for pregnant women taking 1,000 mg of DHA/day compared to 200 mg/day (2.4%).

The rate of late preterm births (between 34 and 37 weeks) was also less for women taking 1,000 mg of DHA/day compared to 200 mg/day.

Finally, low birth weight and the frequency of several maternal and neonatal complications during pregnancy, delivery, and immediately after delivery were also lower with 1,000 mg/day of supplemental DHA than with 200 mg/day.

This confirms the authors’ hypothesis that supplementation with 1,000 mg/day of DHA is more effective than 200 mg/day at reducing the risk of early preterm births. In addition, this study showed that supplementation with 1,000 mg of DHA/day had additional benefits.

This study did not have a control group receiving no DHA. However:

The US average for early preterm births is 2.74%.

For the women in this study who had previous pregnancies, the rate of early preterm birth was 7%.

Of course, the important question for any study of this type is whether all the women benefited equally from supplementation. Fortunately, this study was designed to answer that question.

As noted above, each woman was asked whether they took any DHA supplements at the time they enrolled in the study, and 47% of the women in the study were taking DHA supplements when they enrolled. In addition, the DHA status of each participant was determined from blood samples taken at the time the women were enrolled in the study. When the authors split the women into groups based on their DHA status at the beginning of the study:

For women with low DHA status the rate of early preterm births was 2.0% at 1,000 mg of DHA/day versus 4.1% at 200 mg of DHA/day.

For women with high DHA status the rate of early preterm births was around 1% for both 1,000 mg of DHA/day and 200 mg of DHA/day.

In other words, DHA supplementation only appeared to help women with low DHA status. This is good news because:

DHA status is an easy to measure predictor of women who are at increased risk of early preterm birth.

This study shows that supplementation with 1,000 mg of DHA/day is effective at reducing the risk of early premature birth for women who are DHA deficient.

In the words of the authors, “Clinicians could consider prescribing 1,000 mg DHA daily during pregnancy to reduce early preterm birth in women with low DHA status if they are able to screen for DHA.”

Which Omega-3s Are Beneficial?

DHA is the most frequently recommended omega-3 supplement during pregnancy.

It is not difficult to understand why that is.

DHA is a major component of the myelin sheath that coats every neuron in the brain. [You can think of the myelin sheath as analogous to the plastic coating on a copper wire that allows it to transmit electricity from one end of the wire to the other.]

Unlike other components of the myelin sheath, the body cannot make DHA. It must be provided by the diet.

During the third trimester, DHA accumulates in the human brain faster than any other fatty acid.

Animal studies show that DHA deficiency during pregnancy interferes with normal brain and eye development.

Some, but not all, human clinical trials show that DHA supplementation during pregnancy improves developmental and cognitive outcomes in the newborn.

Recent studies have shown that most women in the United States only get 60-90 mg/day of DHA in their diet.

Clearly, DHA is important for fetal brain development during pregnancy, and most pregnant women are not getting enough DHA in their diet. This is why most experts recommend supplementation with DHA during pregnancy. And this study suggests supplementation with 1,000 mg/day is better than 200 mg/day. However, two important questions remain:

#1: Is 1,000 mg of DHA/day optimal? The answer is, “We don’t know”. This study compared the highest recommended dose (1,000 mg/day) with the lowest recommended dose (200mg/day) and concluded that 1,000 mg/day was better than 200 mg/day.

But would 500 or 800 mg/day be just as good as 1,000 mg/day? We don’t know. More studies are needed.

#2: Can DHA do it all, or are other omega-3s also important for a healthy pregnancy? As noted above, the emphasis on supplementation with DHA was based on the evidence for a role of DHA in fetal brain development during pregnancy.

But is DHA or EPA more effective at preventing early preterm birth and maternal pregnancy complications? Again, we don’t know.

As noted above, the Cochrane Collaboration concluded that omega-3s were effective at reducing early preterm births but was unable to evaluate the relative effectiveness of EPA and DHA because their review included studies with DHA only, EPA only, and EPA + DHA.

This is an important question because the ability of the body to convert EPA to DHA and vice versa is limited (in the 10-20%) range. This means that if both EPA and DHA are important for a healthy pregnancy, it might not be optimal to supplement with a pure DHA or pure EPA supplement.

Based on currently available data if you are pregnant or thinking of becoming pregnant, my recommendations are:

Chose a supplement that provides both EPA and DHA.

Because the evidence is strongest for DHA at this time, chose an algal source of omega-3s that has more DHA than EPA.

Aim for a dose of DHA in the 500 mg/day to 1,000 mg/day range. Remember, this study showed 1,000 mg/day was better than 200 mg/day but did not test whether 500 or 800 mg/day might have been just as good.

As more data become available, I will update my recommendations.

The Bottom Line

The Cochrane Collaboration recently released a report saying that the evidence was definitive that omega-3 supplementation during pregnancy reduced the risk of early preterm births. However, they were not able to reach a definitive conclusion on the optimal dose of omega-3s or the relative importance of EPA and DHA at preventing early preterm birth.

Most experts recommend that pregnant women supplement with between 200 mg/day and 1,000 mg/day of DHA.

A recent study asked whether 1,000 mg of DHA/day was better than 200 mg/day at reducing the risk of early preterm birth. The study found:

The rate of early preterm births (<34 weeks) was less (1.7%) for pregnant women taking 1,000 mg of DHA/day than pregnant women taking 200 mg/day (2.4%).

For women with low DHA status at the beginning of the study, the rate of early preterm births was 2.0% at 1,000 mg of DHA/day versus 4.1% at 200 mg of DHA/day.

For women with high DHA status at the beginning of the study, the rate of early preterm births was around 1% for both 1,000 mg of DHA/day and 200 mg of DHA/day.

The authors concluded, “Clinicians could consider prescribing 1,000 mg DHA daily during pregnancy to reduce early preterm birth in women with low DHA status…”

There are two important caveats:

This study did not establish the optimal dose of DHA. The study concluded that 1,000 mg/day was better than 200 mg/day. But would 500 or 800 mg/day be just as good as 1,000 mg/day? We don’t know. More studies are needed.

This study did not establish the relative importance of EPA and DHA for reducing the risk of early preterm births. DHA is recommended for pregnant women based on its importance for fetal brain development. But is DHA more important than EPA for reducing the risk of early preterm births? Again, we don’t know. More studies are needed.

For more details about this study and my recommendations, read the article above.

These statements have not been evaluated by the Food and Drug Administration. This information is not intended to diagnose, treat, cure, or prevent any disease.

Does Maternal Vitamin D Affect Childhood ADHD?

July 7, 2020 by Dr. Steve Chaney

Can ADHD Be Prevented?

If you are pregnant, or of childbearing age, should you be supplementing with vitamin D? Increasingly, the answer appears to be yes.

1) Based on blood 25-hydroxy vitamin D levels (considered the most accurate marker of vitamin D status):

- 8-11% of pregnant women in the US are deficient in vitamin D (<30 nmol/L).

- 25% of pregnant women have insufficient vitamin D status (30-49 nmol/L).

In short, that means around 1/3 of pregnant women in the US have insufficient or deficient levels of vitamin D. The effect of inadequate vitamin D during pregnancy is not just an academic question.

Why the discrepancy between studies?

Most of the previous studies have been small. Simply put, there were too few children in the study to make statistically reliable conclusions.

Most of the studies measured maternal 25-hydroxyvitamin D levels in the third trimester or in chord blood at birth. However, it is during early pregnancy that critical steps in the development of the nervous system take place.

How Was The Study Done?

Finland is among the northernmost European countries, so sun exposure during the winter is significantly less than for the United States and most other European countries. This time period also preceded the universal supplementation with vitamin D for pregnant women that was instituted in 2004.

- 49% of pregnant women in Finland were deficient in vitamin D (25-hydoxyvitamin D <30 nmol/L) compared to 8-11% in the United States.

- 33% of pregnant women in Finland had insufficient vitamin D status (25-hydroxyvitamin D 30-49.9 nmol/L) compared to 25% in the United States.

Finland, like many European countries, keeps detailed health records on its citizens. For example:

- The Finnish Prenatal Study collected data, including maternal 25-hydroxyvitamin D levels during the first trimester), for all live births between 1991 and 2005.

- The Care Register for Health Care recorded, among other things, all diagnoses of ADHD through 2011.

Thus, this study was ideally positioned to compare maternal 25-hydroxyvitamin D levels during the first trimester of pregnancy with a subsequent diagnosis of ADHD in the offspring. The long-term follow-up was important to this study because the average age of ADHD diagnosis was 7 years (range = 2-14 years).

Does Maternal Vitamin D Affect Childhood ADHD?

The answer to this question appears to be a clear, yes.

If you divide maternal vitamin D levels into quintiles:

Offspring of mothers in the lowest vitamin D quintile (25-hydroxyvitamin D of 7.5-21.9 nmol/L) were 53% more likely to develop ADHD than offspring of mothers in the highest vitamin D quintile (49.5-132.5 nmol/L).

When you divide maternal vitamin D levels by the standard designations of deficient (<30 nmol/L), insufficient (30-49.9 nmol/L), and sufficient (≥50 nmol/L):

Offspring of mothers who were deficient in vitamin D were 34% more likely to develop ADHD than children of mothers with sufficient vitamin D status.

Can ADHD Be Prevented?

Fatty fish and vitamin D-fortified dairy products are the most important food sources of vitamin D. Fatty fish are not everyone’s favorite and may be too expensive for those on a tight budget. Many people are lactose intolerant or avoid milk for other reasons. If you are not eating these foods, you may not be getting enough vitamin D from your diet. This is particularly true for vegans.

If you have darker colored skin, you may have trouble making enough vitamin D from sunlight. If you are also lactose intolerant, you are in double trouble with respect to vitamin D sufficiency.

Obesity affects the distribution of vitamin D in the body. So, if you are overweight, you may have low 25-hydroxyvitamin D levels in your blood.

The vitamin D RDA for pregnant and lactating women is 600 IU, but many multivitamin and prenatal supplements only provide 400 IU. If you are pregnant or of childbearing age, it is a good idea to look for a multivitamin or prenatal supplement that provides at least 600 IU, especially if you are in one of the high risk groups listed above.

Some experts recommend 2,000 to 4,000 IU of supplemental vitamin D. I would not recommend exceeding that amount without discussing it with your health care provider first.

Finally, for reasons we do not understand, some people have a difficult time converting vitamin D to the active 25-hydroxyvitamin D and 1,25-dihydroxyvitamin D in their bodies. If you are pregnant or of childbearing age, it is a good idea to have your blood 25-hydroxyvitamin D levels determined and discuss with your health care provider how much vitamin D you should be taking. Many people need more than 600 IU to reach vitamin D sufficiency status.

Low maternal folate and omega-3 status.

Smoking, drug, and alcohol use.

Obesity.

Sodas and highly processed foods.

In closing, there are three take-home lessons I want to leave you with:

1) The first is that there is no “magic bullet”. There is no single action you can take during pregnancy that will dramatically reduce your risk of giving birth to a child who will develop ADHD. Improving your vitamin D, folate, and omega-3 status; avoiding cigarettes, drugs, and alcohol; achieving a healthy weight; and eating a healthy diet are all part of a holistic approach for reducing the risk of your child developing ADHD.

2) The second is that we should not think of these actions solely in terms of reducing ADHD risk. Each of these actions will lead to a healthier pregnancy and a healthier child in many other ways.

3) Finally, if you have a child with ADHD and would like to reduce the symptoms without drugs, I recommend this article.

The Bottom Line

A recent study looked at the correlation between maternal vitamin D status during the first trimester of pregnancy and the risk of ADHD in the offspring. The study found:

Offspring of mothers who were deficient in vitamin D were 34% more likely to develop ADHD than children of mothers with sufficient vitamin D status.

In the article above I discuss what this study means for you and other factors that increase the risk of giving birth to a child who will develop ADHD.

For more details read the article above.

These statements have not been evaluated by the Food and Drug Administration. This information is not intended to diagnose, treat, cure, or prevent any disease.