Last week I received a little package in the post. It contained some information from a well-known brand of pregnancy multivitamins as well as some “freebies” all branded with the multivitamin logo. I have a very cynical view of advertising aimed at health professionals because I figure that companies wouldn’t be spending the money on freebies, conferences, advertising in professional magazines if it didn’t work, no matter how much health professionals want to say they aren’t influenced. I moaned about this advertising on my personal page and was dismayed to find that quite a few of my friends were recommended a brand of multivitamins in pregnancy by their midwives (actually, the same one that sent me the freebies). This is not the advice I would give as a midwife, so as I said, I was a bit dismayed. I asked on my Bumps, Birth and Bonding Facebook page whether women were recommended a specific brand of multivitamins and got similar responses. Obviously the advertising works!! So… I thought I’d do a bit of counter-advertising (is that a “thing”?) and lay out the facts about what is really necessary in terms of vitamin supplements in pregnancy.
First off… do you even need to take a multivitamin in pregnancy?
Current NHS advice is that pregnant women should get the majority of their vitamins and minerals by eating a healthy diet, but that in addition all pregnant women need to take folic acid and vitamin D in pregnancy.1 A great leaflet can be found here, which explains a healthy diet, foods to avoid and which vitamins you need in pregnancy.
I understand the pressure to take a multivitamin in pregnancy; I’ve done it myself. You want to give your baby the best start and the advertising suggests that taking a multivitamin is essential. However, the evidence doesn’t show that it is necessary and pregnancy multivitamins aren’t cheap. The official guidance that comes through the NHS is based on careful analysis of available evidence and unless there is clear evidence for supplementation, it won’t be recommended (see my references, below, for very comprehensive analyses of the research). This is in contrast to advertising that comes from the multivitamin industry (this refers to all brands) which of course wants you to buy their products, so there is a tendency to make claims based on studies which seem to back up the need for their supplements. NHS recommendations, however, will look at all available evidence and provide a more balanced view. That’s not to say that in a few years further evidence won’t come out saying that another supplement should be added to the “essential” category along with vitamin D and folic acid, but in the meantime I’d be inclined to take advice from an impartial source that doesn’t have a financial interest in getting you to buy a supplement.
You may decide to take a pregnancy multivitamin if you find it hard to eat a heathy diet in pregnancy, or if you are on a low income and struggle to buy food that meets the healthy diet requirements (it is expensive to eat fresh fruit and vegetables, after all). If you are on a low income, you may be entitled to free Healthy Start pregnancy vitamins. If you decide that you do want to take a multivitamin (and there is nothing wrong with taking one even if you still eat a healthy diet, I just want you to be aware of the facts), you really should take a specific pregnancy preparation since most standard multivitamins contain retinol (vitamin A) which can be harmful in pregnancy.
So… I looked at the cost of multivitamin supplements. The “basic” pregnancy vitamins that contain the recommended amounts of folic acid and vitamin D, as well as other vitamins and minerals (brands like Boots, Pregnacare, Seven Seas, as well as many other less known brands) cost between £3.50 and £8.00 for a four week supply. There is no significant difference in composition between these brands, so if you want to take a multivitamin you may as well go for the cheapest you can find. Some brands also include omega 3 oils, and these preparations significantly increase the price of supplementation, to about £13 for a four week supply. There is no strong evidence to support taking omega 3 oils in pregnancy however, in spite of the claims made by the multivitamin companies.2 Pregnacare Max costs nearly £20 for a 28 day supply, and contains the standard pregnancy multivitamins plus omega 3 oils and a different type of folic acid, which I’ll discuss further, below. The only other pregnancy multivitamin that I could find which contains this different type of folic acid is Cytoplan’s pregnancy preparation, although it also contains a higher dose of vitamin D than is recommended, which I’ll also discuss in further detail below.
So… If you decide to take a multivitamin in pregnancy, you are probably going to spend a total of somewhere between £32 and a whopping £180 depending on which preparation you pick, and that’s just for the pregnancy itself, it doesn’t include any multivitamins you may have been taking prior to conception and as I mentioned before…they aren’t necessary if you have a healthy diet. I did mentioned that the only two supplements that are recommended for all pregnant women are folic acid and vitamin D, so let’s look a little bit more in depth at them now and how much they cost.
Folic acid supplementation is universally recommended to women wanting to conceive as it reduces the risk of neural tube defects (spina bifida).3 Folic acid is a synthetic form of folate, which is present in food. The standard dose recommended is 400 microgrammes (mcg), and this is sufficient for most women. Ideally, this should be commenced prior to conception, so as soon as you start planning for a baby, but at least as soon as you get pregnant and continued until you are 12 weeks pregnant. You can continue to take it after 12 weeks if you wish (it really isn’t necessary) but it is crucial in the first trimester as that as when the fetal spinal cord is developing.
Some women are at an increased risk of neural tube defect and so the recommended dose for these women is 5 mg, a significantly higher dose. Women who should take this higher dose include women who have a family history of neural tube defect, a body mass index greater than 30, have diabetes, are on certain epilepsy medication, have coeliac disease, sickle cell disease or thalassaemia.4 In my experience, GP’s don’t always know to prescribe this higher dose of folic acid to at risk women, so don’t be afraid to ask your GP if you think you should be on 5 mg rather than 400 mcg.
Are there any concerns about folic acid? Well, folic acid is a synthetic form of folate. Some people (about 5% of the population) have a gene mutation which makes it difficult for them to metabolise folic acid. An alternative may be a natural form of folate known as 5-methyl-tetrahydrofolate (5-MTHF) sometimes just called methylfolate. Both folate obtained through your diet and folic acid (provided you don’t have the gene mutation) is turned into 5-MTHF in the body.3 Unfortunately, currently there is not sufficient evidence to support supplementing with methylfolate instead of folic acid. This does not mean that it doesn’t reduce the risk of neural tube defects, merely that there haven’t been enough studies to prove that it has the same protective effect as folic acid.3 It stands to reason, though, that if both folic acid and folate are turned into 5-MTHF by the body, taking 5-MTHF should have the same protective effect as folic acid, there just isn’t the evidence – yet. You may feel that standard folic acid is sufficent, and this can be purchased quite cheaply over the counter, or you can get a prescription from your GP for it. If you decide to purchase it, it’ll cost around £1 a month. If you decide to go for the natural form (methylfolate) this will cost a bit more, at around £4 for a month’s supply. You probably won’t be able to pick up methylfolate from your local chemist though, it usually has to be purchased from specialist supplement websites. Don’t forget, it’s only essential to take folic acid until 12 weeks, so no need to buy it after that.
What about vitamin D? Pregnant women are recommended to take 10 microgrammes (µg) throughout their pregnancy (and if breastfeeding, but I’ll cover that in another blog) as vitamin D deficiency can result in poor bone development in babies, and vitamin D taken in pregnancy has been proven to improve bone density in babies.5 The best source of vitamin D is sunlight, which is not something we have in great supply here in Northern Ireland, and it is difficult to get sufficient vitamin D from diet alone as there are few foods which are naturally high in vitamin D.5 As a result, supplementation is recommended. Again, some GP’s don’t seem to be aware of this recommendation (although it has been in place for around 4-5 years) so worth mentioning if you tell them you’re pregnant and you don’t automatically get a prescription.
There may be other benefits to taking vitamin D, and this is where I think the dosing and advice on vitamin D needs more clarification and research. Around 20% of adults are deficient in vitamin D.6 My own personal experience is that I took vitamin D 10 µg for nearly 3 years and when my levels were checked as part of my recurrent miscarriage investigations, my vitamin D levels were below the recommended levels. My vitamin D levels had never been checked before so I may have been severely deficient before I started taking it; or it may be because I’m overweight and fat tissue does seem to reduce the levels of vitamin D in the blood.5 Sadly, it’s not that vitamin D is stored in fat to be released into the body as it is needed, but rather that it just gets sequestered and stored there, where it can’t be used. This is where I think more clarification on the optimum dose of vitamin D is needed. While 10 µg of vitamin D in pregnancy may be sufficient for improving bone density in your baby, it may not be enough to address your own deficiency (remember, 20% of the population is deficient) but since there isn’t a routine policy for testing vitamin D levels, there is no real way of knowing whether you need a higher dose.6 Added to this, there have been claims made that higher doses of vitamin D may help reduce the risk of pre-eclampsia, miscarriage, high blood pressure and diabetes, but there is currently very little evidence for these claims.5,6 This does not mean that vitamin D isn’t beneficial, merely that there isn’t enough evidence yet. Furthermore, while there is no evidence that higher doses of vitamin D in pregnancy cause any harm (the safe upper limit in pregnancy is considered to be 100 µg, or 10 times the current recommended dose), there is probably not enough evidence to say categorically that higher doses than 10 µg are recommended or safe either.5,6 Confusing, right? What would I recommend? Definitely take the recommended dose of vitamin D for a start. If you think you might be deficient or that you would benefit from a higher dose, do your research and discuss it with your GP. Oh, and in terms of cost for vitamin D, you should be able to get it on prescription, but if you decide to buy it, it really isn’t that expensive, less than £1 per month.
To summarise then: Don’t be fooled by the advertising! Sometimes less is more, in this case, more money in your pocket. As long as you have a healthy diet, you can probably get away with spending nothing on vitamin supplements in pregnancy, as your GP should give you a prescription for folic acid and vitamin D, and even if you do want to buy them yourself, they still are very cheap. If you decide to take any further supplements, as with anything, you need to weight up the benefits and potential risks for yourself. Remember that any drug or supplement can have an unintended or unwanted side-effect and just because they are “only” vitamins, doesn’t mean that you shouldn’t exercise caution and restraint, especially if you decide to take supplements (or doses) that aren’t currently recommended.