Pregnancy multivitamins

Are they essential, or just a pricey gimmick?
 
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01 .Introduction

Pregnancy and fertility vitamins

Until recently, the main supplements recommended for pregnancy were folic acid and iron: maternal folic acid (ideally taken before conception) helps prevent spina bifida and other neural tube defects, while increased blood volume and the developing placenta place large demands on iron stores.

These days, there are specialist multi-vitamin and mineral preparations for pregnancy and breastfeeding, as well as conception. Are these supplements a gimmick, or is there good evidence they're beneficial?

Micronutrient requirements of pregnant women

The National Health and Medical Research Council (NHMRC) lists recommended daily intakes of various nutrients for pregnant and breastfeeding women, based on latest available evidence. The key nutrients at issue for pregnant women are as follows:

Iron

Pregnancy increases the need for iron in the diet. Apart from increased vascular blood mass for the mother and placenta, the developing foetus draws iron from the mother to last it through the first five or six months after birth (breast milk is low in iron). Although studies show that absorption of iron can increase substantially during pregnancy, the recommended daily intake (RDI) is 27mg, and vegetarians, vegans and women carrying more than one baby are at risk of iron deficiency.

Folic acid 

The RDI for women is 500 micrograms (mcg) for one month before conception and 600mcg for three months after. In 2009, Food Standards mandated that bread be fortified with folic acid, and two slices contains about 80mcg. This will help, but a supplement is still recommended, as are natural sources such as green vegetables and wholegrains.

Iodine

Iodine is necessary for the normal growth and mental development of a baby, and the RDI for pregnant women is 220mcg and 270mcg for breastfeeding women. After milk producers switched from using iodine-based to chlorine-based cleaners to clean dairy equipment, and more people ditched iodised table salt for gourmet salt – or none at all – iodine deficiency became an issue, with pregnant woman in parts of Australia suffering mild to moderate deficiency in the early 2000s.

Since 2009, bread manufacturers have been required to use iodised salt in all bread except organic bread. This is expected to increase average iodine levels by about 54mcg per day. However, on its own this won’t ensure pregnant or lactating women are getting enough iodine, and a 150mcg supplement is recommended. The NHMRC recommends you avoid kelp and kelp-derived iodine due to mercury poisoning risks.

Vitamin D

Vitamin D helps the body absorb and use calcium. The most recent recommendations are that an adequate intake (AI) for all adults up to the age of 70, including pregnant and lactating women, is 15mcg (or 600 international units) of dietary vitamin D per day, with a safe upper limit of 100mcg (4000 IU). While we can get our vitamin D from the sun, deficiency is an emerging health issue in Australia – studies of the general population show that while few people are moderately or severely deficient in vitamin D, a significant minority (23-49%) have a mild deficiency.

The main risks for deficiency are having dark skin and covering up for religious or cultural reasons. People living in colder southern parts of Australia are also susceptible to deficiency. Obesity is another risk factor, and its prevalence is increasing in Australia – a Queensland study found 14% of pregnant women were obese.

Most people will get enough vitamin D by spending 10 minutes in the morning or late afternoon sun with face, arms and hands exposed; a bit longer in winter (15 minutes or 30 minutes in Tasmania) .

The level of vitamin D found in most pregnancy supplements is less than the recommended adequate intake of 600 IU (Ethical Nutrients Pregnancy Support and Swisse Pregnancy Ultivite being the exceptions). So if you’re at increased risk of deficiency, consult your doctor for advice.

Calcium

A developing foetus needs calcium for healthy bones, teeth, muscles, nerves and heart. Normal levels of recommended calcium intake will suffice, although pregnant teenagers will need extra. For most people, calcium needs can be met through the diet. Women who avoid dairy products or have a vitamin D deficiency may need a supplement.

Vitamin B12

Vitamin B12 is needed for neurodevelopment. It’s only found in animal products (flesh, eggs and dairy) and some types of algae, so vegans may need vitamin B12 daily supplementation of 250-500 mcg. Ethical Nutrients Pregnancy Support contains 500mcg - however, the supplement contains animal-derived ingredients and so isn’t suitable for vegetarians or vegans.

Omega 3 fatty acids

Many supplements contain fish oil, which provides fatty acids essential for the baby’s neural development. The Royal Australian and New Zealand College of Obstetricians and Gynaecologists currently don’t recommend it in the first trimester, due to a lack of evidence supporting its use and a lack of safety data. But they told us that this position is likely to change soon, with more evidence of its safety now available.

Too much of a good thing?

Some vitamins in excess can cause problems. These include:

Vitamin A

Vitamin A is available as retinol or from conversion of beta carotene in brightly coloured fruits and vegetables. The retinol form is found in liver, full-fat dairy products and margarines. The particularly high levels in liver can be toxic and pregnant women are advised to avoid liver and pate for this reason. Vitamin pills tend to contain the beta-carotene form of vitamin A. Avoid those containing retinol.

Vitamin B6

Vitamin B6 may help relieve nausea, though not necessarily vomiting, associated with morning sickness. Many supplements contain 50mg of vitamin B6, which is much greater than the RDI of 1.9mg/day but at the upper level of recommended intake for pregnant women. A typical balanced diet will give you a few milligrams in addition to this, but it’s extremely unlikely you’d get anywhere near the safe maximum of 100mg per day without additional supplements. More than 100 mg per day in the first trimester may be linked to birth defects involving the baby's arms, legs and nerve development.

Iron

The upper intake for iron intake from all sources is 45mg per day, and most supplements have less than this. At higher levels, there is a risk of gastrointestinal upset and constipation, though this can be minimised by taking the pill with food and drinking plenty of water throughout the day. In cases of iron deficiency anaemia, the doctor’s supervision of intake is essential: large amounts of iron can lead to an excessive increase in red blood cells (called haemoconcentration), which thickens blood and slows its flow, causing, paradoxically, the same problems as too little iron: premature birth and low birth weight. Iron supplements are also hazardous for the 1 in 300 people with haemochromatosis, a condition that may not be diganosed in women during their child-bearing years.

 
 

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Clinical trials have shown the benefit of taking vitamins and mineral supplements designed for pregnancy, but almost all have been conducted in low- or middle-income countries where malnutrition is common. The main benefits reported are reduced risk of neural tube defects and maternal anaemia, and where there’s a risk of malnutrition they reduce the risk of low birthweight babies.

If your diet is generally healthy, with plenty of fruit, vegetables, nuts, pulses and dairy products (or calcium-fortified alternatives), you’re unlikely to benefit from a pregnancy supplement. There are many nutritional benefits from food that can’t be obtained from a vitamin pill - and no pill will undo the negatives of a diet of pies, chips and thick shakes.

That’s the ideal. The reality, however, is that many women don’t have a diet that’s healthy in every respect, and some women struggle to eat well if they suffer severe morning sickness, in which case the extra nutrients in pregnancy supplements may be useful.

The Royal Australian and New Zealand College of Obstetricians and Gynaecologists states that “although, in the general population, a healthy balanced diet should largely obviate the need for vitamin and mineral supplementation, pregnancy and lactation create extra nutritional demands that, for some individuals, may make supplementation advisable.”

The college recommends supplements in the following situations, in consultation with your doctor:

  • iodine and folic acid supplementation for all pregnant women.
  • additional folic acid (5mg per day) for women with a multiple pregnancy, taking anti-convulsants, people with diabetes and those who have a tendency to blood clotting or a family history of neural tube defects.
  • vitamin B12 for vegans.
  • iron for vegetarians and vegans, and women with a multiple pregnancy
  • calcium for people who avoid dairy (eg lactose-intolerant or vegan).
  • vitamin D may be necessary for people at risk of deficiency.

“Pregnancy multivitamins won’t cause any harm, and may confer some benefit for women who don’t have a healthy diet,” says Dr Louise Farrell, Chair of the College’s Women’s Health Committee. She points out that maternal micronutrient supplementation and foetal health is a developing science and under continual review.

CHOICE verdict

We looked at the ingredients of various pregnancy and breastfeeding formulations. All contained the recommended intake of folic acid and iodine, which many regular multi-vitamins do not. Many contained unnecessary vitamins and minerals, or pointlessly low levels of nutrients, particularly calcium. If you’re only after the iodine and folic acid, you can buy on price, and whether or not it contains fish oil. Those listed below will cost about 50 cents per day, though heavy discounting can reduce this to less than 30 cents.

  • Some of the cheaper fish oil products include Nature's Own Pregnancy Platinum, Swisse Pregnancy + Ultivite, Microgenics Pregnancy & Breastfeeding Multivitamin and Healthy Care Pregnancy Care & Breastfeeding (available from Chemist Warehouse, this one is by far the cheapest, but doesn't contain vitamin D - if that's an issue for you). Blackmore's Pregnancy & Breastfeeding Gold had a RRP higher than these, but was 'on special' just about everywhere we looked, so it's worth shopping around.
  • Of the products that don't contain fish oil, we found Fabfol Plus and Swisse Pregnancy Ultivite to be slightly cheaper than others.

Breastfeeding - special needs 

After birth, the need for some nutrients, such as iron, decreases from the levels required during pregnancy. But there are increased needs for some nutrients: vitamins A, all the B complex vitamins, C and E, and especially iodine. A healthy diet and increased appetite should ensure adequate levels of most of these nutrients, although an iodine supplement may be necessary.  

There are several micronutrient formulations for women and men trying to conceive.

For women, a folic acid supplement is recommended for one month prior to conception to reduce risks of neural tube defects. Megafol 0.5 is a 500mcg folic acid supplement that costs $2.99 for 100 tablets, or 3c a day. There is no need for any other special supplement at this stage, although if your diet isn’t as healthy and balanced as it should be, now is the time to start good habits to see you through pregnancy and family life.

For men, small studies with low numbers of live births suggest that antioxidants create healthier sperm, and men with low fertility have been found to have lower levels of antioxidants in semen than fertile men. So antioxidant supplements containing vitamins and minerals, such as vitamin E, vitamin C, carotenoids, ubiquinol, folate and zinc are promoted to men for increasing the chances of conception. There’s some evidence they can help, however, it’s based on only a few studies, and further work is recommended to confirm these findings.

Humans produce their own antioxidants and also get some from plant foods, especially fruit and vegetables. As well as diet, excessive exercise, alcohol, smoking, drugs, stress and environmental pollution can contribute to poor sperm health, so this might be the time to spring clean your lifestyle!

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