Personalized Supplements in Pregnancy
Originally written for Dr. Richard Firshein, Layla Health, NYC
Every pregnancy is like a snowflake. They may look similar but each one is a unique composition of genetics, physiology, environment, and lifestyle choices. But as with many recommendations that are meant to span large populations, all women are told to take the same steps to a healthy pregnancy. Unfortunately, this is not always the best advice for those women who may need personalized support.
For instance, most pregnancy guidelines suggest the same vitamin and supplement amounts to all women, irrespective of their medical history or diet. And while pharmaceutical medicine is tailored by their doctor as needed, vitamin recommendations tend to be the same across most pregnancies.
Let us examine a few supplements where personalized advice can be invaluable.
Folic Acid vs. Folate
Folic acid or folate (or Vitamin B9) may be the most common supplement recommended during pregnancy, and even to prepare for pregnancy. And for good reason, since a deficiency in Vitamin B9 increases the risk of neural tube birth defects and miscarriage. It also increases the chances of infertility for women who are not pregnant.
But let us step back and differentiate between folic acid and folate. Although these terms are often used interchangeably, the two are not the same. Folic acid is the synthetic form of Vitamin B9 found in supplements and fortified foods, whereas folate is the natural form found in food. Both need to be converted to an active form the body can use, called methylfolate (5-MTHF.)
MTHFR is an enzyme that converts folic acid and folate to active methylfolate. It has become popularized in holistic healthcare over the past few years because up to 60% of the population is affected by genetic variations that restrict MTHFR from properly converting folic acid into active methylfolate.
If you have one of the MTHRF variants, the inability to properly convert folic acid means it is important to avoid this form in supplements and enriched foods. Since it is found in many foods, such as flour, pasta, bread, cereals, and rice, remember to check the labels. You should also get enough of the folate form in food, or supplements. This is especially important in pregnancy and even before becoming pregnant.
Dietary folate comes in different forms, including some that need to be converted by MTHFR and some that are already in the active form. Therefore, it is important to eat a variety of folate-containing foods, such as dark leafy greens, beef liver, asparagus, broccoli, legumes, avocados, Brussels sprouts, citrus fruits, and nuts and seeds.
Since it is often difficult to obtain enough folate from foods alone, there are many supplements available now that are specifically made for people who have the MTHRF variants and are already in the active 5-MTHF form. They usually have names such as 5-methyltetrahydrofolate, Metafolin, 5-MTHF, and others, depending on the supplement brand. These are biologically active and the body can absorb and use them without any modification.
The only way to know if you have an MTHFR variant is to get tested. And because it is so important to have sufficient levels of this vitamin throughout pregnancy (and even before becoming pregnant) this is an important example where one prenatal supplement does not fit all.
Vitamin D
Having sufficient levels of Vitamin D (also known as “calciferol”) is important for our overall health. It plays a role in maintaining an effective immune system, bone health, reduction of inflammation, and proper cell division.
Although we are still not sure how vitamin D works physiologically, we know it is important to maintain adequate amounts throughout pregnancy, because it reduces the risks of pre-eclampsia and gestational diabetes and may also reduce the risk of low birth weight and severe bleeding after birth. Also, infants who are deficient are at greater risk for impaired bone development.
So how do we get enough of this vitamin? Our main sources are food, sun exposure, and supplements. The most abundant foods are fatty fish such as salmon and trout, but there is also some Vitamin D in beef liver, egg yolks, and cheese. Fortified foods, such as milk and some cereals, are another dietary source.
But because of the many variations in our diets, we do not all get the same amount of Vitamin D from food. And because we are physiologically different, we absorb nutrients and convert them to active forms at different rates as well. And finally, skin pigmentation also affects our ability to generate Vitamin D from sun exposure, with darker skin generating less.
Despite all our differences, the guidelines for Vitamin D intake in pregnancy are the same for all women. The suggested amount is 400-600 IU daily, and most prenatal supplements contain 400 IU. But studies are showing that this amount may not be enough for someone who begins pregnancy with below-normal levels. And given that about 40% of the American population is deficient, this is an important consideration in choosing the right supplement.
In fact, one study found that up to 85% of pregnant women had insufficient levels of Vitamin D (defined as levels below 32 ng/mol.) And this number was even greater for African American women, at 94%. 48% of all women, and 68% of African American women had fully deficient levels (defined as levels below 20 ng/mol.) Moreover, this study found that taking the standard amount of 400 IU did not correct these below-optimal levels. (1)
Another study also concluded that the current guideline of 400 IU was not enough for those who were deficient, especially African American women. This study compared supplementing with different amounts of Vitamin D after the first 12 weeks of pregnancy and concluded that a higher level, up to 4,000 IU, was found to be safe and effective at correcting deficiency. (2)
Of course, this does not mean that every woman who has below-optimal levels of Vitamin D needs the highest supplementation amount of 4,000 IU. But it may mean that the standard amount of 400 IU is not enough. So, if you are pregnant, or plan to become pregnant, consider asking your healthcare provider to check your Vitamin D levels and create a personalized supplementation plan.
Omega 3
Omega 3 fats are another important nutrient for a healthy pregnancy. Two of the most beneficial Omega 3 fats are DHA and EPA, mainly found in fish. DHA is especially important to ensure optimal fetal brain, eye, immune and nervous system development.
And while the best sources of DHA and EHA are fatty fish, environmental pollution has rendered most seafood inappropriate for pregnant women. Although one to two servings per week of fish such as salmon or sardines are safe, a cleaner way to obtain these nutrients is through supplementation.
This is also an example of variation in quality across different supplements. The high-quality supplements process the oil in a way that does not damage the beneficial fats, and removes contaminants such as heavy metals, PCBs, and dioxins. These supplements are also carefully tested. The lower quality supplements may be contaminated and may have damaged nutrients. These should be avoided.
And lastly, if you are pregnant, make sure that your Omega supplement is not made of fish liver, such as cod liver oil, as it can contain too much retinol form of Vitamin A, which may be harmful in pregnancy.
Personalized supplement plan
And of course there are many other examples where the one-size-fits-all approach may leave some women with the wrong kind of supplement or less-than-therapeutic amounts. It certainly doesn't help that most prenatal supplements come as a multi-vitamin. But because of growing demand for personalized healthcare, new supplement options are becoming available. And finding a trusted healthcare professional can help you create a personalized plan unique to your needs.
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