How Does This Relate To Pregnancy, Labor, Birth, And The Postpartum Period?
Author: Carolyn Curtis, MSN, CNM, RN, FACNM, FAAN
Editor: Dr. Steve Chaney
Family History And Pregnancy
On the first prenatal appointment, an extensive history is taken that includes family history, personal medical history, gynecological history, pregnancy history; sexual history, social history.
Due to the many physiological changes that occur during pregnancy, birth and the postpartum period, one can be placed at increased risk for the development of health conditions that may not have been present prior to pregnancy.
A properly collected and granular family history may determine if a woman is at increased risk for disease, identify early warning signs of disease; and assist the provider in recommending treatments for reducing a woman’s risk for developing serious problems in during pregnancy, labor, birth and the postpartum period.
A recent study (D Rasooly et al, J Am Heart Assoc, 12(22): e030779, 2023) published in 2023 presents findings on the association between a comprehensive family history that includes parents, siblings and the self-reported personal history of obesity, diabetes, and heart and blood conditions.
How Was This Study Done?
The study involved 125,430 participants; 66.3% were women; 33.75 were men; 75.7% were White; 10.4% were Hispanic; 3.3% were Asian; 8.3% were Black and 2.4% were Other.
The study provided information on the possibility of someone developing a health problem based upon their family history. It also reported odds ratio (statistical probability) of other conditions developing when one health condition was present.
The Importance Of Family History For Maternal Health
The findings of the study were as follows. Of the 125,430 participants:
A family history of hypertension or high blood pressure was reported by 51.6% of the participants. When this was disaggregated by race, 60% of Blacks reported having a family history of hypertension and 54.4% of Asians reported having hypertension compared to 48.6% of Whites.
A family history of high cholesterol was reported by 38.7% of the participants.
A family history of heart attack was reported by 23.6% of the participants.
A family history of Type 2 diabetes was reported by 21.4% of the participants.
If one has a family history of a certain medical condition, there is an increased likelihood that this same condition can be passed on to the next generation (in this case, the pregnant mother). The statistical term “odds ratio” means the likelihood of this same condition occurring in the next generation when there is a family history vs when there is not a family history.
Passing the Same Disease Down To The Pregnant Mother
Compared to those who do not have a family history, here are the odds for passing down these same conditions to the mother.
Hypertension – 2.56 times the odds it can be passed down.
High cholesterol – 2.89 times the odds. If there is a family history of high cholesterol, there is 2.44 odds of Asians developing high cholesterol compared to 2.16 odds in the Black population.
Coronary Artery Disease – 3.54 the odds.
Type 2 diabetes – 3.79 times the odds.
Anemia – 2.66 times the odds.
Peripheral vascular disease – 6.60 times the odds.
Pulmonary embolism/deep vein thrombosis – 5.60 times the odds.
Obesity – 1.2 times the odds. If there is a family history of obesity, for Asian populations, there is 2.93 odds that obesity will be passed down to son or daughter. This ratio is 4.57 in the Black population.
Passing Another Disease Down To The Pregnant Mother
The study also reported the association of family history to someone’s personal health condition and the odds of the pregnant mother developing a different health condition pertaining to obesity, diabetes and heart and blood. On average there was 1.5 odds of developing a different condition from the condition reported in the family history. For example:
When there is a family history of Type 2 diabetes, there is 2.04 odds of developing obesity.
When there is a family history of pulmonary embolism/deep vein thrombosis; there is 3.25 odds of developing a bleeding disorder.
The two family health conditions that had the most evidence of association with other conditions were family history of stroke and heart attack.
When there is a family history of stroke, the odds of the pregnant mother developing other conditions are as follows:
Obesity (1.35).
Heart attack (1.7). There was almost double the odds ratio in the Hispanic population with 3.34 odds.
Hypertension (1.40). Whites reported 1.37 odds for developing hypertension compared to 1.55 for Blacks and 1.43 for underrepresented populations.
High cholesterol (1.33). When disaggregated by race, Whites had a 1.29 odds ratio; Black a 1.60 odds ratio and those underrepresented in biomedical research had a 1.33 odds ratio.
When there is a family history of heart attack, the odds of the pregnant mother developing related conditions are as follows:
Heart attack (2.17). These odds are decreased for Asians (1.92) and Hispanics (1.27).
Coronary artery disease (1.97).
Congestive heart failure (1.54).
High cholesterol (1.44).
When there is a family history of Type 2 diabetes, the odds of the pregnant mother developing other conditions are:
Heart attack (1.32).
Congestive heart failure (1.44).
Bleeding disorder (1.26).
Coronary artery disease (1.37 odds).
Asians with a family history of Type 2 diabetes have a 1.79 odds of developing heart valve disease.
How Does This Relate To Pregnancy, Labor, Birth, And The Postpartum Period?
The five main causes for pregnancy related death in the United States (defined as maternal death up until 12 months after giving birth) are:
Mental Health – 24%.
Hemorrhage – 14%.
Cardiovascular Disease – 13%.
Cardiomegaly (enlarged heart) – 9%.
Blood Clots – 9%
Many of these causes are related to the cardiovascular system. Based upon the data in this study, a family history of any of the following can contribute to the increased odds of developing health problems during pregnancy:
Stroke
Type 2 diabetes
Pulmonary embolism/deep vein thrombosis
Hypertension
Anemia
Once someone knows their family history, when planning for a pregnancy, they can work on any nutrition or lifestyle changes needed to reduce the incidence of problematic health conditions occurring during pregnancy and the health of the newborn.
The US Surgeon General has published My Family Health Portrait which will allow individuals to record and share their family history. It can be accessed at https://cbiit.github.io/FHH/html/index.html
The Bottom Line
When planning a pregnancy, a thorough family health and personal history is important.
Obesity, diabetes and heart and blood conditions can be passed from parents to children. Some of these conditions include anemia, peripheral vascular disease, pulmonary embolism/deep vein thrombosis, Type 2 diabetes, hypertension, coronary artery disease, and high cholesterol.
There is an association between a family history of stroke and heart attack and numerous other health conditions.
One’s family history can impact health conditions experienced during pregnancy that can result in pregnancy-related death up to 12 months after the baby is born.
The US Surgeon General’s My Family Health Portrait is an online tool that can help families to record their family health history and share with other family members.
For More Information
Feel free to visit my website, subscribe to my YouTube channel and learn more about my online coaching program, “Mastering Pregnancy and Birth”.
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 posts on this website 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.
More than 40 years’ experience in the oversight of domestic and international programs and the provision of nursing and midwifery integrated service delivery in maternal child health, family planning, reproductive and women’s health care.
Twenty years’ experience in teaching, mentoring, and providing clinical oversight to undergraduate and graduate public health, medical, nursing and midwifery students.
About The Editor
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.
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.
How do the myths of the food supplement industry originate? Some of them start innocently enough. They are often based on a kernel of truth which is misinterpreted by some well-meaning medical doctors.
It’s not their fault. We teach future doctors what I call “metabolism light” in medical school. There simply isn’t room in the medical curriculum to teach all the details and nuances of human metabolism.
We also try to teach them the basics of how to interpret scientific literature. However, it takes years of experience to get good at picking out the strengths and weaknesses of clinical studies.
The doctors form their hypothesis and test it on a few patients. If it works, they publish a paper. At that point their idea is picked up by the “sensationalist” bloggers. These are the bloggers who like to focus on the sensational. They delight in writing about “new findings” that go against what the medical profession has been telling you for years.
The bloggers don’t stop there. They usually expand the claims. They ‘cherry pick” the scientific literature by quoting only studies that support their viewpoint and ignoring studies that refute it. In short, they put together a very compelling story. Soon the story is picked up by other bloggers who embellish it further. After it appears in enough sites, people start believing it. A myth is born.
Then supplement companies get in the act. They sense there is money to be made. They manufacture supplements to provide nutrients supported by the myths. They embellish the mythology even more and put together a compelling story to market their products.
This is where the mythology becomes deception. Companies have the responsibility to design their products based on the best science. They have an obligation to tell the truth about their products. When they make claims they know cannot be true, they are lying to you.
The saga of methylfolate is a perfect example of how observations based on a kernel of truth became myths and eventually became downright lies. Let me share that story with you.
The Kernel Of Truth About Methylfolate
Let’s start with one of the “kernel of truth” that launched the whole methyl folate saga. It started with a doctor who was having a very difficult time finding a solution for a patient with some significant health issues. The doctor ordered a genetic test and discovered the patient had a deficiency in the methylene tetrahydrofolate reductase (MTHFR) gene.
The doctor remembered the reaction catalyzed by MTHFR, and a light bulb went off. “Eureka”, he said. His patient must be unable to make N5-methyltetrahydrofolate (commonly referred to as methylfolate or methyl folate), and methylfolate is required for some very important methylation reactions in the cell.
He gave his patient methylfolate, and the patient’s symptoms got better. The doctor leapt to the conclusion that other patients with MTHFR deficiency needed methylfolate as well. Many of those patients responded to methylfolate as well. He didn’t bother to check whether they responded equally well to folic acid. He just assumed methylfolate was the magic elixir.
He wrote a paper on his clinical observations, and the methylfolate story was launched. It all seemed so logical.
However, the story was not nearly as straight forward as the doctor and the people publicizing his findings assumed. Let me walk you through some “Metabolism 101”. Don’t worry. There won’t be a quiz.
Why The Original Assumptions About Methyl Folate Were Misleading
MTHFR mutants only have a partial loss of activity.
Individuals with 2 copies of a mutation from A to C at position 1298 of the MTHFR gene (A1298C homozygotes) comprise about 5% of the US population. They have 60% enzyme activity and appear to be normal in clinical studies.
Individuals with 2 copies of a mutation from C to T at position 677 of the MTHFR gene (C677T homozygotes) have 30% enzyme activity. They comprise about 10% of the US population. C677T homozygotes often have elevated homocysteine levels. The homozygous C677T mutation is associated with depression, anxiety, and mood swings in some people, but not in others (I will come back to the significance of that qualifying statement later).
C677T heterozygotes (one mutant gene) have 65% activity and are normal.
We Don’t Need 100% MTHFR Activity
Our human body is wonderfully designed. For many of our most essential metabolic reactions we have built in redundancy. We don’t require 100% activity of key enzymes. This helps protect us from bad effects of mutations as they arise.
The best analogy I can think of is the US space program. Most space vehicles had built in redundancy so that if one system failed, the mission could go on. For example, you may remember the Hubble space telescope. It was launched with four gyroscopes to keep the telescope pointed in the right direction.
After a few years, one gyroscope gave out. That was not a problem because there were three left. A few years later the second gyroscope gave out. Again, there was no problem because there were still two gyroscopes left.
It was only after the third gyroscope gave out that Hubble became a bit “wonky”, and a space shuttle was sent up to replace the gyroscopes. It is the same with MTHFR. Only when you get down to around 30% activity, does it become a bit wonky”. (That’s about as non-technical as I get.)
Not Everyone With MTHFR Deficiency Experiences Symptoms
This is due to a phenomenon my geneticist friends refer to as penetrance. Simply put, that means that not everyone with the same mutation experiences the same severity of symptoms. That is because the severity of a mutation is influenced by diet, lifestyle, and genetic background.
Let me start with genetic background. In terms of MTHFR mutants you can think of genetic background as being mutations in a related methylation pathway. People who have a mutation in both MTHFR and a gene in a related pathway will experience more severe symptoms and are more likely to require methylfolate. Once you understand penetrance, you realize that individuals requiring methylfolate may represent only a small subset of people with MTHFR mutations.
Penetrance is a concept that most proponents of the methylfolate hypothesis completely ignore. The most severe MTHFR mutation (C677T homozygote) increases the probability that individuals will exhibit symptoms, but some individuals with that mutation are completely normal. Now that you understand the concepts of redundancy and penetrance, you can understand why that is.
When Did The Kernel of Truth Become A Myth?
Up to this point the hype around methyl folate could be chalked up to an honest misunderstanding.
The doctors who published the original papers may not have known that MTHFR mutations only resulted in a partial reduction in enzyme activity.
They probably didn’t know the concepts of redundancy (our cells don’t need 100% enzyme activity) or penetrance (the same mutation may cause severe symptoms in some patients and have no effect in others).
It seemed logical to assume that everyone with a MTHFR mutation might do better with methylfolate supplementation. That was incorrect, but it was an honest mistake.
However, the message was picked up by the bloggers who specialize in sensational stories, especially stories that contradict what experts have been telling you for years. They picked up the methylfolate story and distorted it beyond recognition.
They knew that “natural” is a buzz word, so they told you that methylfolate was natural and folic acid is synthetic.
They told you that methylfolate was better utilized than folic acid.
They told you that methylfolate was more effective than folic acid.
They told you folic acid was toxic. It was going to increase your risk of cancer.
Suddenly, it was no longer about people with MTHFR deficiency. You were told that everyone should avoid folic acid and use methylfolate instead.
On the surface, these pronouncements should not have passed the “If it sounds too good to be true…” test, or in this case, the “If it sounds too bad to be true…” test. You were being asked to believe that folic acid, which has been in use for over 80 years and is backed by hundreds of studies showing it is safe and effective, was neither safe nor effective. You were asked to believe that the government was poisoning you by fortifying foods with folic acid.
However, to make their blogs sound more convincing, they listed clinical studies supporting their stories. The problem is they “cherry picked” the studies that supported their story and ignored the rest. Their bias was particularly outrageous when it came to the “story” that folic acid increases cancer risks. They ignored 10 or 20 studies showing no cancer risk and reported one suggesting it might increase risk. I call that deceptive.
Unfortunately, the myths created by the bloggers have been repeated often enough that many people now believe they are true. It is time for me to debunk the methylfolate myths.
The Methylfolate Myths
Myth: Methylfolate is natural. It comes from whole food. Folic acid is synthetic.
Fact: Methylfolate is chemically synthesized from folic acid. It is physically impossible to extract enough from whole foods. Here are the facts:
Methyfolate is only one of several naturally occurring folates in foods.
The best food sources of folates are beans, leafy greens, and broccoli.
To obtain the RDA of methyfolate for a single tablet you would need to start with 1 cup of lentils, two cups of cooked spinach, or 4 cups of broccoli.
You do the math! It just isn’t possible.
Myth: Methylfolate is better utilized by the body than folic acid.
Fact:This claim is based on levels of methylfolate in the blood after taking supplements providing equivalent amounts of methylfolate and folic acid. However, methylfolate has no biological activity in our blood. The measurement that matters is total folate levels (methylfolate plus other folates) in our cells.
If you take equivalent amounts of folic acid and methylfolate, you end up with identical folate levels in your cells (B.J. Venn et al, The Journal of Nutrition, 132: 3333-3335, 2002). In short, there is no difference in our ability to utilize methylfolate and folic acid.
Myth: If you have a mutation in the MTHFR gene, folic acid isn’t effective.
Fact: MTHFR slightly increases the need for folic acid (from 400 ug to between 600 and 800 ug), but multiple studies show that folic acid supplementation is effective in people with MTHFR mutations.
For example, homocysteine levels are easily measured and are a reliable indicator of methylfolate status.
That study also showed that folic acid was more effective than methylfolate at lowering homocysteine in people who were C677T heterozygotes and in people with normal MTHFR activity.
At present, lowering of homocysteine levels is the only indicator of methylfolate status for which methylfolate and folic acid have been directly compared. However, there are other studies suggesting that folic acid is likely to be effective for people with MTHFR defects. For example:
Fact: The few studies suggesting that folic acid supplementation might increase the risk of cancer were “outliers”. By that I mean they contradicted many other studies showing no increased risk.
Scientists are accustomed to this. We know that studies sometimes come up with conflicting results. In some cases, we can point to an error in experimental design or statistical analysis as the cause of the aberrant results.
In other cases, we never know the reason for the differences, so we go with the weight of experimental evidence (what the majority of studies show). The weight of evidence clearly supports the safety of folic acid.
However, that is not enough. If there is the slightest possibility that something causes cancer, we investigate it further. Consequently, the scientific community followed up with larger studies.
Those studies showed either reduced cancer risk or no difference in cancer risk with folic acid supplementation. None of the studies found any evidence that folic acid increased cancer risk. I have covered this in detail for folic acid and colon cancer risk in a previous issue of “Health Tips From The Professor”.
There have also been a couple of small studies suggesting that folic acid might increase the risk of prostate and breast cancer. Although these were small, individual studies, they have been widely hyped by the methylfolate advocates. Once again, the definitive study has been done (S.E. Vollset et al, The Lancet, 381: 1029-1036, 2013).
It was a meta-analysis of 13 placebo-controlled studies involving over 50,000 subjects. The results were clear cut. Folic acid supplementation caused no increase in overall cancer risk, and no increase in the risk of colon cancer, prostate cancer, breast cancer, or any other individual cancer. Moreover, the average dose of folic acid in those studies was 2 mg/day, which is 5 times the RDA.
Of course, the bloggers and the companies selling methylfolate supplements ignore the definitive studies showing folic acid does not increase cancer risk. The myths and lies continue.
Myth: Folic acid can mask a B12 deficiency.
Fact: True but irrelevant if you use a supplement with folic acid and B12 in balance.
The Lies Of The Supplement Industry
If you are writing a blog, you are covered by “freedom of speech”. You can say whatever you want. It doesn’t have to be true. However, if you are a supplement manufacturer, you are held to a higher standard. Ignorance is no longer an excuse. You can no longer cherry pick the “facts” you like and ignore the rest. You are ethically obligated to research all the available literature and be guided by the best scientific evidence.
Reputable companies have been guided by scientific evidence and have not jumped on the methylfolate bandwagon. They know folic acid is both safe and effective in a wide variety of clinical situations. They also know that, while methylfolate may be just as effective as folic acid, it has not been shown to be superior to folic acid for any clinical application.
They may offer a methylfolate option for people who believe they need it. But they make no claim that it is superior to their products containing folic acid.
Less reputable companies, however, sensed money to be made by capitalizing on the buzz around methyl folate. They repeated the myths of the bloggers and claimed their products were superior to others on the market. They call it marketing. I call it lying. They have an obligation to fact check their claims and only make claims that are true.
Let me give you an example. In preparing for this article, I looked at the claims of several companies that were promoting their methylfolate supplements. One in particular claimed they had studies showing:
1) Their methylfolate supplement was effective at reducing the risk of adverse pregnancy outcomes.
2) Their methylfolate supplement was twice as bioavailable as folic acid.
3) Their methylfolate supplement was able to lower homocysteine levels better than conventional folic acid supplementation.
All three studies were bogus.
With respect to the first study, it was likely true that their methylfolate supplement decreased adverse pregnancy outcomes. But there are dozens of studies showing that folic acid does the same thing.
And because they did not compare methylfolate and folic acid supplementation in their studies, they have no basis for claiming their supplement was superior.
The second study compared levels of methylfolate and folic acid in the blood. As I mentioned above, methylfolate has no biological activity in our blood. The measurement that matters is total folate levels (methylfolate plus other folates) in our cells. And previous studies have shown that equivalent amounts of methylfolate and folic acid give identical amounts of methyfolate in our cells.
The third study compared their supplement, which contained B6, B12, zinc, and betaine in addition to methylfolate, to folic acid alone. That’s comparing apples to oranges. That is because there are three pathways for lowering homocysteine levels, and B6, B12, and betaine play important roles in each of these pathways.
B12 is an integral part of the enzyme methionine synthase, an enzyme that converts homocysteine to the amino acid methionine. Methylfolate transfers its methyl group to the enzyme-bound vitamin B12, and methyl B12 transfers the methyl group to homocysteine, which converts it to methionine. In other words, methylfolate cannot lower homocysteine levels by itself. It needs vitamin B12.
Betaine also serves as a methyl donor in another pathway for converting homocysteine to methionine by an enzyme called betaine-homocysteine methyltransferase.
B6 is essential for yet another pathway that lowers homocysteine levels by converting homocysteine to the amino acid cysteine.
You might argue that the company was simply ignorant of the importance of B6, B12, and betaine for lowering homocysteine levels. However, that is unlikely. Why else would they have included B6, B12, and betaine in their supplement?
They must have known the study they designed was bogus. That suggests they conducted the study with the sole purpose of deceiving you, the consumer. I call that lying.
Finally, in case you were wondering, I am not recommending you select a single supplement with folic acid, B6, and B12. I do recommend you get your folic acid from a multivitamin or B complex supplement that provides all three B vitamins in balance.
Betaine deficiency is very rare, so I don’t include betaine in my recommendations.
What Does This Mean For You?
MTHFR mutations only result in partial loss of activity. Most individuals with MTHFR defects remain symptom free with the RDA, or slightly above the RDA, of folic acid.
However, there may be some individuals with a MTHFR defect and additional gene defects in metabolic pathways involving methylation who might benefit from methylfolate. This is due to a phenomenon that geneticists call penetrance and would likely represent a small subset of the population with MTHFR defects.
Finally,the claims that everyone would benefit from methylfolate instead of folic acid are false. They are contradicted by human metabolism and multiple published clinical studies.
In short, folic acid has been used for over 80 years. There are hundreds of clinical studies showing it is safe and effective, even in most individuals with a MTHFR deficiency. I can’t tell you whether the companies selling methylfolate are ignorant of basic metabolism and the published studies refuting their claims or whether they are purposely trying to deceive the public—but neither is a good thing.
The Bottom Line
Some supplement manufacturers are claiming that methylfolate is more natural and more effective than the folic acid that has been used in supplements for the past 80 years. In this issue of “Health Tips From the Professor” I debunk the methylfolate myths used by the supplement manufacturers to sell their methylfolate products.
I can’t tell you whether the companies selling methylfolate are ignorant of basic metabolism and the published studies refuting their claims or whether they are purposely trying to deceive the public—but neither is a good thing.
For more specifics, 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.
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 textbooks 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 53 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.
Between 2018 and 2021, the maternal mortality (death) rate in the United States nearly doubled, placing the country last among developed nations in maternal health outcomes. The maternal mortality ratio (MMR) is a key indicator of a nation’s overall health, making this rapid increase a cause for serious concern.
Understanding Maternal Mortality
Maternal mortality refers to the number of women who die during pregnancy or within 42 days (six weeks) after childbirth for every 100,000 live births. As per the Government Accounting Office, 25% of the increase in maternal mortality from 2020 to 2021 was due to Covid-19, which contributed to the doubling of the maternal mortality ratioi.
The maternal mortality ratio is used globally to assess the state of a country’s health. A rising MMR signals the need for urgent action.
In 2022, the U.S. recorded an overall maternal mortality ratio 22.3 deaths per 100,000 live birthsii. This decreased by about 10 deaths per 100,000 from 2021 (32 deaths per 100,000 live births in 2021). However, stark racial disparities continued to exist as demonstrated through 2018 to 2021.
Black women: 49.5 deaths per 100,000 live births (more than 2.5 times the rate for white women)
White women: 19.0 deaths per 100,000 live births
Hispanic women: 16.9 deaths per 100,000 live births
Asian women: 13.2 deaths per 100,000 live births
Maternal Mortality versus Pregnancy Related Deaths
What Is The Difference?
While maternal mortality measures deaths that occur from the onset of pregnancy to six weeks post-delivery, pregnancy-related deaths extend further. Pregnancy-related deaths are the number of deaths per 100,000 live births up to 12 months (one year) after birth or the first birthday.
Does The Age Of The Mother Make A Difference?
The age of the mother significantly affects the risk of dying during pregnancy. The ratio of deaths among women younger than 25 years of age is 14.4 deaths per 100,000 live births. Women aged 25 to 39 have a rate of 21.1/100,000 live births, while those aged 40 and older face a staggering 87.1 deaths per 100,000 live birthsiii. This means that women over 40 are dying at six times the rate of those under 25 and four times the rate of women aged 25 to 29iv.
When Are The Deaths Occurring?
Surprisingly, a little under half (47%) of maternal deaths occur during pregnancy or within the first week postpartum (Maternal Mortality). And a little over half (53%) happen between one week and one year after childbirth or the baby’s first birthday (Pregnancy-Related Deaths).
Leading Causes Of Maternal Deaths
The primary causes of maternal mortality in the U.S. are largely preventablev. The six main causes of maternal death include:
Mental Health Conditions (23%) – Suicide, overdose, and substance-related poisoning are the leading causes, this affects White and Hispanic women more than Black or Asian women.
Hemorrhage (14%) – Severe postpartum bleeding remains one of the top causes of maternal deaths not only in the Unites States but throughout the world with Asian women being more susceptible. Hemorrhage is defined as bleeding about one half quart of blood.
Cardiac Conditions (13%)– Heart disease disproportionately affects Black women.
Blood Clots (9%) – A major contributor to maternal deaths.
Cardiomyopathy (9%) – A condition affecting the heart muscle, making it harder to pump blood efficiently.
Hypertensive Disorders of Pregnancy (7%) – relating to high blood pressure
Contributors to maternal death include familial, societal, health care system issues and one’s personal health. it is possible to reduce the risks of maternal death by understanding one’s personal health history and your family’s health history.
This information informs nutritional, behavioral and lifestyle changes that can be made prior to and during pregnancy to reduce health risks, enabling a healthier pregnancy outcome.
The Bottom Line
The United States has the highest maternal mortality rate amongst all developed countries in the world.
The maternal mortality rate in the U.S. has nearly doubled between 2018 and 2021; Covid-19 caused a 25% increase of maternal deaths from 2020 to 2021 which contributed to the doubling of maternal deaths. Black women have been disproportionately affected, with mortality rates 2.5x that of White women.
Women aged 40 and over die at four times the rate of women ages 25 to 39 and six times more than women under 25 years of age.
The leading causes of maternal deaths include mental health conditions, hemorrhage, cardiac conditions, blood clots, and cardiomyopathy— most of which are preventable.
Almost half of maternal deaths occur throughout pregnancy and the first week after childbirth. A little more than half of maternal deaths occur from the first week following birth up to the first year after birth. It’s important to continue monitoring mothers with home visits once they return home from the hospital and up until one year after birth.
References
i General Accounting Office, Maternal Health: Outcomes Worsened and Disparities Persisted During the Pandemic. Oct, 2022.
ii Hoyert DL. Maternal mortality rates in the United States, 2022. NCHS Health E-Stats. 2024. DOI:https://dx.doi.org/10.15620/cdc/152992.
Mastering Pregnancy and Birth Coaching Program – A program that prepares Dads and Mom’s-to-be for a healthier pregnancy and safer birth. This course also provides information for Doulas to provide enhanced support to families.
Carolyn Curtis
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.
About The Author
Carolyn Curtis, MSN, CNM, RN, FACNM, FAAN, has:
More than 40 years’ experience in the oversight of domestic and international programs and the provision of nursing and midwifery integrated service delivery in maternal child health, family planning, reproductive and women’s health care.
Twenty years’ experience in teaching, mentoring, and providing clinical oversight to undergraduate and graduate public health, medical, nursing and midwifery students.
About The Editor
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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).
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.
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.
If you are pregnant, you want the best for your unborn baby. Your doctor has recommended a prenatal supplement, but do the prenatal supplements on the market meet your needs? A few months ago, I sharedtwostudies that concluded that most prenatal supplements on the market are woefully inadequate.
In fact, the authors said, “[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.
Now, a third study on the topic has been published (KA Saunders et al, American Journal of Clinical Nutrition, 117: 823-829, 2023. It differs from the previous studies in that:
1) The previous two studies took a comprehensive approach, while this study focused on 6 key nutrients.
The previous studies included all nutrients important for a healthy pregnancy including choline, iodine, and vitamin K, which have only recently been shown to be important for a healthy pregnancy.
This study focused on 6 nutrients, vitamin A, vitamin D, folic acid, calcium, iron, and omega-3 fatty acids, which have long been recognized as essential for a healthy pregnancy.
2) The previous two studies focused on prenatal supplements, while this study focused on all supplements that might be taken by pregnant women.
3) The previous two studies asked whether supplements provided recommended amounts of all nutrients needed for a healthy pregnancy. This study took a “Goldilocks approach” and asked whether levels of these 6 essential nutrients were appropriate (“just right”). The study:
Started by determining the intake of these 6 key nutrients by American women. The authors of the study then added the amount of each nutrient provided by the supplements in their study to the amount of that nutrient in the diet of American women and:
Calculated the minimum amount of each nutrient that would be needed to assure that 90% of American women taking a particular supplement would meet the recommended intake for pregnant and lactating women.
Calculated the maximum amount of each nutrient provided by supplements in their study to assure that that 90% of American women taking that supplement would not get potentially toxic amounts of that nutrient.
In other words, for each of the 6 nutrients they calculated a supplemental dose range that was neither too low nor too high. They called this the “appropriate dose range” for each nutrient. Goldilocks would have called it “just right”.
I’m sure you are anxiously waiting to learn what their study found. But before we go there, I will describe how the study was done.
How Was The Study Done?
For the dietary intake portion of the study, the authors used dietary intake data previously collected from the Environmental Influences on Child Health Outcomes (ECHO) study.
The ECHO study is a consortium of 69 medical centers across multiple states. It is an observational study of mothers and their offspring designed to understand the effects of early life exposures on child health and development.
The current study analyzed dietary intake data for 2450 participants from 6 medical centers across 5 states in the ECHO study. The women in this study were diverse with respect to ethnicity, education, and weight.
All pregnant women in the current study completed at least one 24-hour dietary recall between 6-week gestation until delivery (24% completed one dietary recall. 76% completed two or more dietary recalls). Dietary intake was generally assessed with an expert interviewer and included all foods and beverages consumed in the previous 24 hours.
For the supplement portion of the study, the authors used the NIH Dietary Supplement Label Database because it is the most complete listing of supplements in the US. The authors selected 20,547 supplements that contained at least one of the 6 essential nutrients from this database.
To determine which of the 20,547 supplements contained appropriate levels of the 6 nutrients (vitamin A, vitamin D, folic acid, calcium, iron, and omega-3 fatty acids) selected for this study, the authors used the process described in the introduction above. Briefly:
The authors added the amount of each nutrient provided by the supplements in their study to the amount of that nutrient in the diet of American women and:
Calculated the minimum amount of each nutrient that would be needed to assure that 90% of American women taking a particular supplement would meet the recommended intake for pregnant and lactating women.
Calculated the maximum amount of each nutrient provided by supplements in their study to assure that that 90% of American women taking that supplement would not get potentially toxic amounts of that nutrient.
In other words, for each of the 6 nutrients they calculated a supplemental dose range that was neither too low nor too high. They called this the “appropriate dose range” for each nutrient.
Why Are The 6 Nutrients Included In This Study Important?
Dietary Intake Is Often Inadequate
The diet analysis of pregnant American women in this study found:
42% were at risk of inadequate vitamin A intake.
96% were at risk of inadequate vitamin D intake.
45% were at risk of inadequate folic acid intake.
55% were at risk of inadequate calcium intake.
93% were at risk of inadequate iron intake.
67% were at risk of inadequate omega-3 intake.
The percentage of women at risk for inadequate intake of these nutrients varied with age, ethnicity, and income levels. But the overall message is clear. Most American women are not getting enough of these essential nutrients from their diet alone.
The Risk of Inadequate and Excessive Intake Of These Nutrients
These 6 nutrients were chosen in part because reviews by the Cochrane Collaboration have concluded that inadequate intake of these nutrients are associated with complications during pregnancy and delivery. They can also adversely affect the health and normal development of the baby.
This is important because the Cochrane Collaboration is considered the Gold Standard of clinical studies. You can find a more detailed description of Cochrane Collaboration studies and why they are the Gold standard here.
[Note: The Cochrane Collaboration has not yet evaluated choline, iodine, and vitamin K for pregnant women, but their inclusion in prenatal supplements is supported by multiple clinical studies.]
In addition, excess intake of all these nutrients except omega-3s can harm both the fetus and the mother. The is why the Food and Nutrition Board has set ULs (Upper Limits – the level above which toxicity can occur) for 5 of the 6 nutrients. This is important because previous studies have suggested that up to 25% of women may be getting toxic levels of one or more of these nutrients when you consider both their dietary intake and their prenatal supplement.
Summary
In other words, both too little and too much of these nutrients can harm the mom and her baby. It is critical that prenatal supplements get the dosing right.
It is for that reason that the authors of this study have set an “appropriate dose range” (high enough that 90% of women have enough of each nutrient to prevent deficiency and low enough that 90% of women do not exceed the UL for each nutrient) as the standard for evaluating the adequacy and safety of supplements for pregnant women.
Prenatal Supplements Strike Out Again
Of the 20,547 supplements (421 labeled as prenatal supplements) available on the US market as of December 31, 2022, the investigators reported that:
Only 69 (0.3%) supplements contained all 6 nutrients considered essential for a healthy pregnancy.
Only 1 supplement contained all 6 nutrients at the appropriate doses, and it wasn’t even labeled as a prenatal supplement.
In addition:
One supplement containing all 6 nutrients put 100% of the women in their study at risk for excessive intake of folic acid.
Another supplement containing all 6 nutrients put 46% of the women in their study at risk of inadequate calcium intake.
The authors concluded, “Almost no US dietary supplements provide key nutrients in the doses needed for pregnant women. Affordable and convenient products that fill the gap between food-based intake and estimated requirements of pregnancy without inducing excess intake are needed to support pregnant women and their offspring.”
In short, the conclusion of this study can be summed up as, “Prenatal Supplements Strike Out Again”.
[Note: It sometime takes a while for supplement labels to be posted in the NIH Dietary Supplement Label Database. The authors acknowledged that this study may not include supplements introduced or reformulated in the last quarter of 2022.]
Is It Three Strikes And You Are Out?
If you are pregnant or thinking of becoming pregnant, this should be a wake-up call.
70% of pregnant women in this country take prenatal supplements, usually based on recommendations by their health care provider. They assume the prenatal supplements meet their needs and the needs of their unborn baby.
Yet three studies evaluating the adequacy of prenatal supplements have been published in the past few months. They took very different approaches in evaluating the supplements. But all three studies concluded that the vast majority of prenatal supplements on the market are woefully inadequate.
You may be wondering, “Is it three strikes, and you are out?” Are there no decent prenatal supplements on the market? The answer to those questions is, “No. There are good prenatal supplements on the market.”
You may be wondering how I can say that in the face of such overwhelming negative data. That’s because while all 3 studies were very good studies, they each had “blind spots”:
1) Each of the studies used very stringent criteria for identifying adequate prenatal supplements. In some cases, their criteria were stricter than the RDA recommendations and the recommendations of the American College of Obstetrics and Gynecology for pregnant and lactating women. It could be argued that their criteria were too stringent.
2) In the case of the current study, it could also be argued that evaluating only 6 nutrients is not a good criterion for evaluating the adequacy of prenatal supplements. For example, I looked up the one supplement rated as adequate in this study. It does provide appropriate doses of the 6 nutrients this study focused on. It also provides appropriate doses of vitamin K and iodine. But it does not provide choline. It is a very good supplement for women, but it is not the perfect prenatal supplement.
So, what can you do? How can you find the best prenatal supplement for you? Unfortunately, you cannot rely on advice from your friends or your health professional. You cannot rely on advertisements. That is a good place to start, but you have to do your own sleuthing.
With that in mind, I have listed 7 simple rules for selecting the best possible prenatal supplement in my article about the first two studies. Use these rules for evaluating every prenatal supplement you come across. Happy sleuthing.
The Bottom Line
A recent study evaluated all 20,547 supplements on the US market to see if they met the needs of pregnant women in this country.
They focused on 6 nutrients (vitamin A, vitamin D, folic acid, calcium, iron, and omega-3s) known to be essential for a healthy pregnancy.
They determined the dietary intake for all 6 nutrients in a cross section of pregnant women in the US.
They added the amount of the 6 nutrients in each of the 20,547 supplements to the dietary intake of those nutrients by pregnant women.
They then asked which supplements provided the “appropriate dose” of all 6 nutrients. They defined “appropriate dose” as the dose range that was.
High enough to prevent deficiency of that nutrient in 90% of pregnant women taking the supplement…and…
Low enough to prevent toxicity from that nutrient in 90% of pregnant women taking the supplement.
In other words, for each of the 6 nutrients they calculated a supplemental dose range that was neither too low nor too high.
Of the 20,547 supplements (421 labeled as prenatal supplements) available on the US market:
Only 69 (0.3%) supplements contained all 6 nutrients they considered essential for a healthy pregnancy.
Only 1 supplement contained all 6 nutrients at the appropriate doses, and it wasn’t even labeled as a prenatal supplement.
The authors concluded, “Almost no US dietary supplements provide key nutrients in the doses needed for pregnant women. Affordable and convenient products that fill the gap between food-based intake and estimated requirements of pregnancy without inducing excess intake are needed to support pregnant women and their offspring.”
[Note: It sometime takes a while for supplement labels to be posted in the NIH Dietary Supplement Label Database. The authors acknowledged that this study may not include supplements introduced or reformulated in the last quarter of 2022 or early 2023.]
If you are pregnant or thinking of becoming pregnant, this should be a wake-up call.
70% of pregnant women in this country take prenatal supplements, usually based on recommendations by their health care provider. They assume the prenatal supplements meet their needs and the needs of their unborn baby.
Yet three studies evaluating the adequacy of prenatal supplements have been published in the past few months. And all three studies concluded that the vast majority of prenatal supplements on the market are woefully inadequate.
You may be wondering, “Is it three strikes, and you are out?” Are there no decent prenatal supplements on the market? The answer to those questions is, “No. There are good prenatal supplements on the market.”
You may be wondering how I can say that in the face of such overwhelming negative data. That’s because while all 3 studies were very good studies, they each had “blind spots”:
For more details on this study and 7 tips on finding the best prenatal supplement 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.
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?”
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.
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.
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
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.
Should you eat more fish?
Should you take omega-3 supplements?
Or should you just ignore the claims about omega-3s and a healthy pregnancy?
These are not trivial questions. Let’s consider preterm births as an example. The medical profession has made enormous advances in keeping premature babies alive. However, premature babies are still at higher risk of several health conditions including:
Visual impairment.
Developmental Delay.
Learning difficulties.
Plus, it is expensive to keep premature babies alive. One recent study estimated that increasing omega-3 intake during pregnancy could reduce health care costs by around $6 billion in the United Stated alone.
Unfortunately, it’s not just omega-3s and pregnancy. The same is true for almost all nutritional health claims. One day a study comes out claiming that nutrient “X” cures some disease or has some miraculous benefit. The bloggers and news media hype that study. Suddenly you see that health claim everywhere. It becomes so omnipresent that you are tempted to believe it must be true.
But wait. A few months later another study comes to opposite conclusion. Now the media is telling you that health claim is false. The months come and go, and new studies keep coming out. Some support the health claim. Others refute it.
Pretty soon the nutrition headlines just become “noise”. You don’t know what to believe. If you want the truth, “Who ya gonna call?”
Who Ya Gonna Call?
It’s not Ghostbusters. It not Dr. Strangelove’s health blog. It’s a group called the Cochrane Collaboration.
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.
The Cochrane Collaboration reviews all the relevant studies on a topic, exclude those that are biased or weak, and make their recommendations based on only the strongest studies. Their reviews are considered the gold standard of evidence-based medicine.
If you are of a certain age, you may remember that TV commercial “When EF Hutton talks, people listen.” It is the same with the Cochrane Collaboration. When they talk, health professionals listen.
This week we will examine the Cochrane Collaboration’s review titled “Omega-3 Fatty Acid Addition During Pregnancy”.
How Was The Study Done?
For this analysis the Cochrane Collaboration reviewed 70 randomized controlled trials which compared the effect of added omega-3s on pregnancy outcomes with either a placebo or a diet no added omega-3s. These trials included almost 19,927 pregnant women.
In one sense, Cochrane reviews are what is called a “meta-analysis”, in which data from numerous studies are grouped together so that a statistically significant conclusion can be reached. However, Cochrane Collaboration reviews differ from most meta-analyses found in the scientific literature in a very significant way.
Many 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 that 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. Simply put, the conclusions from some published meta-analyses are not worth the paper they are written on.
The Cochrane Collaboration also reports statistically significant conclusions from their meta-analyses. However, they also 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 as follows:
High-quality evidence. Further research is unlikely to change their conclusion. This is generally reserved for conclusions backed by multiple high-quality studies that have all come to the same conclusion. These are the recommendations that are most often adopted into medical practice.
Moderate-quality evidence. This conclusion is likely to be true, but further research could have an impact on it.
Low-quality evidence. Further research is needed and could alter the conclusion. They are not judging whether the conclusion is true or false. They are simply saying more research is needed to reach a definite conclusion.
Omega-3s Reduce Preterm Births
Here are the conclusions that the Cochrane Collaboration said 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 omega-3s and placebo are not needed at this point.”
In other words, they are saying this conclusion is definite. Omega-3 supplementation should become part of the standard of medical care for pregnant women.
However, they 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 the Cochrane study. Their review and meta-analysis 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).
Do Omega-3s Make For A Healthy Pregnancy?
What about the effect of omega-3s on other pregnancy outcomes?
The conclusions the Cochrane Collaboration said were supported by moderate quality evidence included reductions in:
Perinatal death.
Admissions to the neonatal intensive care unit.
There was not enough high or moderate quality data to determine the effect of omega-3s on other pregnancy outcomes such as postnatal depression. More research is still needed in those areas. However, if you do receive any of these benefits from omega-3 supplementation, you can just consider them as side benefits.
What Does This Report Mean For You?
1) The proven effect of omega-3 supplementation on preterm births is significant because preterm births increase the risk of:
Visual impairment.
Developmental Delay.
Learning difficulties.
2) The likely effect of omega-3s on admission to neonatal intensive care units is significant because those units are very expensive.
3) The Cochrane study did not determine whether omega-3 supplementation was equally important for women at low, moderate, and high likelihood of poor pregnancy outcomes.
Therefore, omega-3 supplementation should be considered for all pregnant women.
4) The Cochrane study did not determine whether omega-3 supplementation was equally important during the first, second, or third trimester.
Therefore, omega-3 supplementation should be considered by all women of childbearing age who might become pregnant and throughout pregnancy.
5) The Cochrane study did not determine whether DHA, EPA, or a mixture of the two was most effective.
Therefore, your omega-3 supplement should probably contain both DHA and EPA. A group of experts recently recommended that adults consume at least 650 mg/day of omega-3s with ≥ 220 mg of that coming from DHA and ≥ 220 mg/day coming from EPA.
Since most pregnant women in this country consume around 89 mg/day of DHA + EPA, omega-3 supplementation is warranted.
The Bottom Line
The effect of omega-3s on pregnancy outcomes have been confusing. Some studies conclude that omega-3s are important for a healthy pregnancy. Other studies suggest they are ineffective. What are you to believe?
Fortunately, a group called the Cochrane Collaboration recently conducted a comprehensive review of this topic. This is significant because Cochrane Reviews are internationally recognized as the highest standard in evidence-based health care. They influence the treatment protocols recommended by the medical community.
This Cochrane Review concluded that omega-3 supplementation during pregnancy:
Reduces preterm births and low birth weight infants.
Likely reduces perinatal death and admissions to the neonatal intensive care unit.
The authors of the review said: “Omega-3 supplementation during pregnancy is an effective strategy for reducing the risk of preterm birth…More studies comparing omega-3s and placebo are not needed at this point.”
In other words, they are saying this conclusion is definite. Omega-3 supplementation should become part of the standard of medical care for pregnant women.
For more details on 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.
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 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.
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.
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.
On the first prenatal appointment, an extensive history is taken that includes family history, personal medical history, gynecological history, pregnancy history; sexual history, social history.
The findings of the study were as follows. Of the 125,430 participants:
The two family health conditions that had the most evidence of association with other conditions were family history of stroke and heart attack. 
The five main causes for pregnancy related death in the United States (defined as maternal death up until 12 months after giving birth) are:
Carolyn Curtis, MSN, CNM, RN, FACNM, FAAN, has:
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.
