“We often get calls on our hotlines from patients who are taking very large doses of supplements, mostly in the mistaken belief that more is better,” says Beth Conover, a pediatric nurse practitioner and director of Nebraska MotherToBaby, an information service about medication exposure during pregnancy. “I don’t think women receive enough information about supplement use in pregnancy.”
Conover’s comments come after a wave of stories around supplement use during pregnancy focusing on iodine in particular. Worldwide, an estimated 1.9 billion people suffer from iodine deficiency and pregnant women are particularly at risk. In Europe, around two-thirds of pregnant women are iodine deficient.
Pregnant and breastfeeding women need more iodine as they produce higher levels of thyroid hormones and pass on the mineral to their baby. A deficiency can lead to miscarriage, stillbirth, preterm delivery, and babies may be born with congenital abnormalities affecting, for example, hearing and mental development.
In a study published this August, researchers suggest that iodine supplements are the way forward, offering a cost-effective way for pregnant women to stay healthy. However, as Conover points out, dietary supplements must be approached with caution. A 2012 study, published in Journal of Pediatrics, suggested that women who take too much supplemental iodine during pregnancy risk giving birth to babies suffering from congenital hypothyroidism, a thyroid deficiency that can lead to heart problems, and to mental and growth retardation.
The same applies to other nutrients. Folic acid is widely known to be one of the staples of a healthy pregnancy, reducing the likelihood of children being born with malformations such as spina bifida. From the early 90s, foods have been fortified with folic acid and the rate of these birth defects has decreased significantly. However, the pendulum has now swung in the other direction and women taking folic acid supplements on top of eating enriched foods risk masking vitamin B12 deficiencies, which are associated with anemia and cognitive impairment.
The dilemma is ongoing. A recent study by Professor Alessandro Laviano of Sapienza University, Rome, pointed to the high health burden still created by malnutrition in high-income countries. Laviano suggests that oral nutritional supplements have the potential to stave off the crisis and save European healthcare systems €170 billion a year.
Janet Fyle, policy advisor at the UK’s Royal College of Midwives, says that ideally, nutrition should come from food, not supplements.
“As midwives, we really want to convey the importance of a balanced diet,” Fyle told the Pregnancy and Medicine Initiative. “Aim to include fresh fruit and veg, protein and an appropriate intake of carbohydrates.”
“Supplements are more expensive than food, if you know where to shop. Also, supplements may not supply micro-nutrients.”
Most experts agree with Fyle that, ideally, all pregnant women would have the resources to eat healthily. However, the reality is that many are struggling. In the current economic climate, not only may some women feel that fresh fruit and vegetables are unaffordable, support is being cut at institutional level and nutrition services at health centers are often among the first services to be cut.
Subsidized oral supplements may then provide a solution, if an imperfect one. However, Conover says that better information is essential.
“Most people forget that supplements are really similar to medications,” she says. “Even though they’re sold everywhere and, in the US, not regulated by the FDA. Pregnant women may not mention their supplement use to their healthcare provider because they don’t think of the supplements as an issue. When I give lectures to medical students and residents I always remind them to ask their patients about their use of supplements.”
Nutritional inequalities mirror financial ones and Europe’s maternal malnutrition problem isn’t easily solved. First and foremost, better education is vital. Without adequate information, women are unable to make the right choices and risk harm from poor nutritional choices. As Conover says, this is not the minor consideration many believe it to be.