08. The Prenatal Quick Start Guide

On the interplay of micronutrients.

As someone who is very susceptible to good packaging and a well-timed Instagram ad (I see you Ritual!), I want to introduce my prenatal "four horsemen," or the gotchas I wish I had known when starting a prenatal. There are many considerations when choosing a prenatal, or vitamins in general, but here are four quick red flags you can look for before clicking that alluring "add to cart." 

Folate, or B9, is arguably the vitamin that started the whole prenatal craze. In the 1980s and 1990s, major studies showed folate's role in preventing neural tube defects, which kicked off a series of public health campaigns and fortifying foods with folic acid.¹ The only issue is that the body finds it easier to use methylated folate (L-methylfolate) than folic acid.² Methylated folate is the active, bioavailable form of folate, so it doesn't require conversion and is ready for the body to use immediately. In contrast, folic acid (the synthetic form found in supplements and fortified foods) requires several steps for conversion into L-methylfolate, especially involving the MTHFR enzyme.³* All to say, look for a prenatal with L-methylfolate and NOT folic acid. The best food sources of folate are beef liver, dark leafy greens, legumes, asparagus, and Brussels sprouts.

Choline, folate's enigmatic cousin, was not considered an essential nutrient until 1998. Studies have determined its vital role in fetal brain development, cell membrane integrity, gene expression, and liver support.⁴ Due to its relatively new status as "essential," it is often missing from prenatal diets. Make sure this is part of your prenatal ingredient list. The best food sources include egg yolks, liver, fish, red meat, and poultry, with lower amounts available in cruciferous vegetables and peanuts. 

Iron is an essential mineral that supports red blood cell production but unfortunately iron deficiency is the most frequent nutritional deficiency in the world today.⁵ But pay close attention; you do not want this micronutrient in your prenatal. Why? Many vitamins and minerals have highly synergistic and antagonistic relationships with one another. Iron, in particular, does not play well with calcium, zinc, magnesium, copper, and vitamin E, which should all be in your prenatal.

Moreover, iron supplementation tends to cause digestive issues. Ideally, you can source iron from food, mainly heme iron, found in red meat, poultry, and fish. Non-animal-based iron sources are non-heme, which makes it harder for the body to absorb. One thing that helps is pairing non-heme sources like lentils, beans, nuts, and leafy greens with Vitamin C. You can also talk to your healthcare provider, naturopath, nutritionist, etc., about gentler forms of iron supplementation.

DHA, or docosahexaenoic acid, is a specific omega-3 fatty acid prone to oxidation, so it is often omitted from prenatals to extend shelf-life. DHA is primarily found in fish and algae and is crucial for brain, eye, and nervous system health, particularly during pregnancy and early childhood.⁶ If choosing to supplement in addition to a foundational prenatal, you have some options. There are specific DHA supplements, or you can take a more bio-available form, such as cod liver oil, krill oil, or algae oil. The benefits of a more bioavailable option like cod liver oil contain both DHA and EPA (eicosapentaenoic acid), another omega-3, as well as vitamins A and D. The added vitamins make it beneficial for immune health, bone health, and skin health in addition to its omega-3 benefits. The downside, then, is making sure the combined amounts of these additional vitamins (across your prenatal and any other supplements) are still within the upper limit. Overload is unlikely, as many prenatals keep dosages fairly low to make pills less bulky, but it is worth taking a look at.

Morning line-up with methylated folate, cod liver oil, and desiccated beef liver (!)

The ingredient list for all prenatals is extremely long, and we could go on at length about each item, but this is what I wish I had known when starting prenatals years ago. Remember, we looked at the timeframe for starting a prenatal in a past post, ideally at least three months before conception. Once the baby is born, please continue taking your prenatal for at least three to six months to support your body through this incredible change. Or if you're like me and want to get pregnant again, just keep taking it :)

🧡

*A note on MTHFR: For people with MTHFR gene mutations, converting folic acid to its active form can be inefficient, which may result in lower levels of usable folate in the body.

MTHFR gene variants are fairly common:

1. C677T Variant:

   • About 25-35% of people of European descent carry one copy of the C677T variant (heterozygous).

   • 10-15% have two copies of this variant (homozygous), which can significantly reduce MTHFR enzyme activity.

   • This variant is less common in people of African or Asian descent.

2. A1298C Variant:

   • Around 30-40% of people of European and Asian descent carry one copy of the A1298C variant.

   • Around 10-15% of people are homozygous for this variant, but it generally has a milder effect on enzyme function than the C677T variant.

3. Compound Heterozygous (C677T + A1298C):

   • Some people carry one copy of each variant (compound heterozygous), which can also impact enzyme function but typically less so than being homozygous for C677T.

Due to these variants, a significant portion of the population may have some degree of reduced MTHFR enzyme activity, affecting their ability to convert folic acid to its active form, L-methylfolate.

1. Prevention of neural tube defects: results of the Medical Research Council Vitamin Study. MRC Vitamin Study Research Group. Lancet. 1991 Jul 20;338(8760):131-7. PMID: 1677062.

2. Scaglione, F., & Panzavolta, G. (2014). Folate, folic acid and 5-methyltetrahydrofolate are not the same thing. Xenobiotica, 44(5), 480–488. https://doi.org/10.3109/00498254.2013.845705

3. Laura Tafuri, Edouard J Servy and Yves J R Menezo. The hazards of excessive folic acid intake in MTHFR gene mutation carriers: An obstetric and gynecological perspective. https://www.researchgate.net/profile/YvesMenezo/publication/324697309_The_hazards_of_excessive_folic_acid_intake_in_MTHFR_gene_mutation_carriers_An_obstetric_and_gynecological_perspective/links/5ae0d143a6fdcc91399ec019/The-hazards-of-excessive-folic-acid-intake-in-MTHFR-gene-mutation-carriers-An-obstetric-and-gynecological-perspective.pdf?uid=65253c6d69

4. Zeisel, S. H. (2013). Nutrition in pregnancy: the argument for including a source of choline. International Journal of Women’s Health, 5, 193–199. https://doi.org/10.2147/IJWH.S36610

5. Friedrisch JR, Friedrisch BK. Prophylactic Iron Supplementation in Pregnancy: A Controversial Issue. Biochemistry Insights. 2017;10. doi:10.1177/1178626417737738

6. Matrices, Maria. Is there a dietary requirement for DHA in pregnancy? https://www.sciencedirect.com/science/article/abs/pii/S0952327809000957