The Right Ingredients

Ingredients, represented by spices. Photo by Calum Lewis on Unsplash

(Photo by Calum Lewis on Unsplash)

The right ingredients should be obvious. They should be the ones that are recognized by worldwide experts as important. They should be dosed in the forms that are most beneficial for infant and baby. 

Where the trouble crops up is that these worldwide organizations don’t always seem to agree. What's more, most prenatal vitamin manufactures don't actually care. They've been making the stuff for years and have no reason to change. The Society of Obstetricians and Gynaecologists of Canada (SOGC) and the American College of Obstetricians (ACOG) and Gynecologists, which are the organizations certifying obstetricians and gynecologists in their respective countries, only agree that you should supplement 5 ingredients between the two of them. Folic Acid, vitamin D, vitamin B12, Iron, and Calcium (see the table below). SOGC does recognize that taking folic acid “in a multivitamin supplement”1 is beneficial, without specifying the composition of the multivitamin.

 So where does that leave your doctors, who depend on these organizations to guide them and help them make the best decisions about your health? Well… in the dark. If you compare the ingredients on different over the counter prenatal vitamins, you’ll see vastly different ingredient lists both in terms of what is included and how much.

The bottom line here is that If nobody can agree, then you’re stuck deciding what’s best for you: (a) supplement with what the science is clear on for benefits for you and your baby during pregnancy, and limit adverse effects and potential contamination from all the extra stuff, or (b) supplement with everything and expose yourself and your baby to… everything, whether scientifically proven or not. It's also important to realize that just because most women don't get enough of a certain nutrient doesn't mean that supplementing with it improves pregnancy outcomes. Supplementing is not the same as getting a nutrient from your diet, and I'm not afraid to say it: eating a healthy diet is far more important than taking a prenatal vitamin, even though a prenatal is important too.

 We decided to take a bottom-up approach to creating this vitamin. Instead of including everything “just in case”, we followed these rules:

 

  1. Is it explicitly recommended by an organization trusted by doctors?
  2. Is it an amount equal to or less than the recommended daily value from Health Canada for pregnant women?
  3. What amount is the average pregnant woman missing from her diet to get to their recommended intakes?

 

If there was disagreement between the above steps, we used our judgement and we wrote about it here. If there was no high quality recommendation from a trusted source, the vitamin wasn’t included. Simple as that.

Below you can see a table of which organization recommends what ingredient, how much the typical woman gets in her diet, and what we decided to include in our formula. We want to share our research so that everyone can be better informed.

IMPORTANT: Our product is still under development. Amounts below may change based on what can reasonably fit inside a pill. We will keep you posted!

Recommendations for healthy women at average risk for neural tube defects*

 

UK National Health Service (NHS)2

Society of Obstetricians and Gynaecologists of Canada (SOGC)1,3

American College of Obstetricians and Gynecologists (ACOG)4

Other

Average daily intake (women aged 20-29, 2015-16, USA)5

Recommended Dietary Intake for Pregnant Women >18 years old

(Health Canada6)

Upper Limit of Tolerable Intake (Health Canada)6

Our Formula

Folic Acid

Supplement 400 mcg

Supplement 400-1000mcg depending on risk for neural tube defects3

400mcg

WHO: 400mcg7

486 DFE (Dietary Folate Equivalents)**

600mcg DFE

1000 mcg DFE

400mcg

Vitamin D

Supplement 400IU

nutrient of concern. Supplements recommended if at risk for deficiency

600IU/day from dietary sources. Do not to supplement routinely “beyond that contained in a prenatal vitamin”8

 

4.1mcg

(164 IU)

15mcg (600IU)

100mcg (4000IU)

 

400 IU

B12

Possible Defficiency if vegetarian / vegan

Supplement

2.6 mcg

Supplementation not specified

 

5.69 mcg

2.6 mcg

N/A

2.6 mcg

Iron (elemental)***

Possible Defficiency if vegetarian / vegan

Supplement 16-20mg

Should meet recommended daily allowance of 27mg/day. Supplementation not specified.

 

12.4mg

27 mg

45 mg

16mg

Vitamin A

AVOID

 

Should meet recommended daily allowance. Supplementation not specified.

 

565 mcg

770 mcg

3000 mcg

none

Iodine (elemental)

 

nutrient of concern

-

>150mcg iodine in addition to diet. (American Thyroid Association and others10). Same during breastfeeding (American Academy of Pediatrics11)

-

160 mcg

1100 mcg

150mcg

DHA (Omega-3 fatty acids)

-

nutrient of concern. Eat >150g fatty fish per week. Avoid those high in mercury.

At least two servings of fish or shellfish per week. Supplementation not specified.

 

See discussion below on Omega 3 fatty acids.

 

50mg

 

-

N/A

200mg from vegan source

Calcium (elemental)

Important in pregnancy. Supplementation not specified.

nutrient of concern. Supplementation is recommended for those with inadequate consumption

Supplementation is recommended for those with inadequate consumption

WHO recommends supplementing in populations with low dietary intake7.

870mg

1000 mg

2500 mg

250 mg

Choline

-

Nutrient of concern during pregnancy

-

American Medical Association recommends supplementing with “evidence based amounts”12

297mg

450mg (pregnancy) 550mg (lactation)

3500 mg

200 mg

 

*Women with risk factors for having infants with neural tube defects should speak to their doctor about the appropriate amount of folic acid to take. It may be more than what is found in a standard prenatal pill.

**DFE is Dietary Folate Equivalents. This is used when comparing folic acid from supplements with folate from food, which is 1.7 times more potent13. Note that there is no established upper limit for folate from food, only for synthetic folic acid14.

***Elemental refers to the element, not the entire ingredient. For example, 80mg of ferrous sulfate (the ingredient) contains 16mg of iron (the element)

Supplementing with Omega-3: the debate 

Avocado representing omega-3. Photo by Wimber Cancho on Unsplash

 

 

 

 

 

 

 

 (photo by Photo by Wimber Cancho on Unsplash)

At the moment, whether or not to supplement with omega-3 fatty acids is a topic of debate. It is well accepted that getting enough omega-3 is beneficial for your baby, and its biggest benefit appears that it may reduce preterm deliveries (at the expense that it may also may increase post-term deliveries)15. There also seems to be a consensus that every woman should get enough from diet, including the opinion of Health Canada which recommends diet as the only potential source16.

 What is less clear is whether or not to include DHA in supplement form. The World Health Organization17 and International Society for the Study of Fatty Acids and Lipids18 actively recommend that pregnant women consume 200mg DHA but stop short of making a recommendation on supplementing to this amount.

On the other hand, March of Dimes19 recommends an average of 200mg DHA per day from diet or supplementation, and UpToDate recommends supplementing with 200-300mg DHA per day in women who are not getting enough from their diet20, which very few women are.

Our Take

We have put a lot of thought into whether or not to include DHA in this formula. We have decided to offer DHA as a vegetarian source of omega-3 fatty acid in our supplement for the following reasons:

The data is clear on the fetal benefit of DHA, and it is also clear that most (American) women do not consume anywhere close to the recommended amount of DHA in their diet5. What’s more, vegetarians and vegans cannot get appreciable amounts of DHA from diet unless they supplement (or eat algae), since ALA, the regular land plant source of omega-3 (think flax seeds), is not efficiently converted into DHA or EPA in our body. DHA appears to be the powerhouse in terms of perinatal benefits.

Most organizations either recommend supplementation or abstain, and the one opinion from Health Canada not to supplement is dated from 2009. We believe that recommendations will change with some impressive new studies recently out and we are proud to be on the forefront.

References

  1. O’Connor DL, Blake J, Bell R, et al. Canadian Consensus on Female Nutrition: Adolescence, Reproduction, Menopause, and Beyond. J Obstet Gynaecol Can. 2016;38(6):508-554.e18. doi:10.1016/j.jogc.2016.01.001
  2. Vitamins, minerals and supplements in pregnancy - NHS. nhs.uk. https://www.nhs.uk/conditions/pregnancy-and-baby/vitamins-minerals-supplements-pregnant/. Published December 21, 2017. Accessed September 12, 2019.
  3. Wilson RD, Wilson RD, Audibert F, et al. Pre-conception Folic Acid and Multivitamin Supplementation for the Primary and Secondary Prevention of Neural Tube Defects and Other Folic Acid-Sensitive Congenital Anomalies. J Obstet Gynaecol Can. 2015;37(6):534-549. doi:10.1016/S1701-2163(15)30230-9
  4. ACOG Committee Opinion No. 762: Prepregnancy Counseling. Obstet Gynecol. 2019;133(1):e78. doi:10.1097/AOG.0000000000003013
  5. WWEIA Data Tables : USDA ARS. https://www.ars.usda.gov/northeast-area/beltsville-md-bhnrc/beltsville-human-nutrition-research-center/food-surveys-research-group/docs/wweia-data-tables/. Accessed September 13, 2019.
  6. Canada H. Dietary Reference Intakes. aem. https://www.canada.ca/en/health-canada/services/food-nutrition/healthy-eating/dietary-reference-intakes/tables/reference-values-elements-dietary-reference-intakes-tables-2005.html. Published July 20, 2005. Accessed August 30, 2019.
  7. World Health Organization, ed. WHO Recommendations on Antenatal Care for a Positive Pregnancy Experience. Geneva: World Health Organization; 2016.
  8. ACOG Committee on Obstetric Practice. ACOG Committee Opinion No. 495: Vitamin D: Screening and supplementation during pregnancy. Obstet Gynecol. 2011;118(1):197-198. doi:10.1097/AOG.0b013e318227f06b
  9. Alexander EK, Pearce EN, Brent GA, et al. 2017 Guidelines of the American Thyroid Association for the Diagnosis and Management of Thyroid Disease During Pregnancy and the Postpartum. Thyroid. 2017;27(3):315-389. doi:10.1089/thy.2016.0457
  10. AAP Recommendations on Iodine Nutrition During Pregnancy and Lactation | Letters to the Editor | Pediatrics. https://pediatrics.aappublications.org/content/134/4/e1282.1#ref-4. Accessed September 16, 2019.
  11. AAP Policy Statement: Council on Environmental Health. Iodine Deficiency, Pollutant Chemicals, and the Thyroid: New Information on an Old Problem. Pediatrics. 2014;133(6):1163-1166. doi:10.1542/peds.2014-0900
  12. AMA backs global health experts in calling infertility a disease | American Medical Association. https://www.ama-assn.org/delivering-care/public-health/ama-backs-global-health-experts-calling-infertility-disease. Accessed September 27, 2019.
  13. Food Labeling: Revision of the Nutrition and Supplement Facts Labels. Federal Register. https://www.federalregister.gov/documents/2016/05/27/2016-11867/food-labeling-revision-of-the-nutrition-and-supplement-facts-labels. Published May 27, 2016. Accessed September 14, 2019.
  14. Office of Dietary Supplements - Folate. https://ods.od.nih.gov/factsheets/Folate-HealthProfessional/. Accessed September 14, 2019.
  15. Middleton P, Gomersall JC, Gould JF, Shepherd E, Olsen SF, Makrides M. Omega‐3 fatty acid addition during pregnancy. Cochrane Database Syst Rev. 2018;(11). doi:10.1002/14651858.CD003402.pub3
  16. Canada H. Prenatal Nutrition Guidelines for Health Professionals - Frequently Asked Questions. aem. https://www.canada.ca/en/health-canada/services/canada-food-guide/resources/prenatal-nutrition/guidelines-health-professionals-frequently-asked-questions.html#i1. Published April 16, 2009. Accessed July 30, 2019.
  17. WHO | Marine oil supplementation in pregnancy and maternal and neonatal health outcomes. WHO. http://www.who.int/elena/titles/commentary/fish_oil_pregnancy/en/. Accessed July 30, 2019.
  18. Koletzko B, Cetin I, Brenna JT, et al. Dietary fat intakes for pregnant and lactating women. Br J Nutr. 2007;98(5):873-877. doi:10.1017/S0007114507764747
  19. Vitamins and other nutrients during pregnancy. http://www.marchofdimes.org/pregnancy/vitamins-and-other-nutrients-during-pregnancy.aspx. Accessed July 30, 2019.
  20. Oken, Emily. Fish consumption and marine n-3 long-chain polyunsaturated fatty acid supplementation in pregnancy. UpToDate. March 2019. https://www.uptodate.com/contents/fish-consumption-and-marine-n-3-long-chain-polyunsaturated-fatty-acid-supplementation-in-pregnancy#H82571245. Accessed August 30, 2019.