During prenatal care, you will be reminded to take folic acid and calcium, but what about vitamin B2?
Vitamins in the B complex play an important role in supporting a healthy pregnancy and to the health of breastfeeding mothers.
Vitamin B2, part of the vitamin B complex is also known as Riboflavin. it is water soluble, which means that your body doesn't store it. You must replace them through your diet or prenatal vitamins.
Why vitamin B2 during pregnancy?
In general, there are many health benefits of vitamin B2:
• Headaches - Vitamin B2 can prevent headaches and treat migraine headaches. It reduces the pain you feel during a migraine attack and stops them from lasting too long.
• Energy - Vitamin B2 is an important part of the metabolic process. The body uses it to properly digest food to give us the energy we want. So without it, we don't process food properly and end up gaining weight and not having the energy to get through the day. Vitamin B2 breaks proteins down into their amino acid bases, fats and carbs by converting them into glucose; the main fuel of the body.
• Cancer - Vitamin B2 is responsible for the production of glutathione which removes these free radicals from breaking down our bodies and keeps the liver clean. Free radicals do a lot of damage to the body and are the main reason you get sick. (1)
During pregnancy, consumption of vitamin B2 lowers the risk of developing preeclampsia, a pregnancy complication. It also promotes the healthy development and growth of baby's bones, muscles and nerves. For moms, vitamin B2 helps your skin look glowing and refreshed! Don't you want to look radiant even when you are pregnant? This is also because vitamin B2 increases blood circulation for mother and foetus and helps prevent pregnancy-related anaemia.
Not only that! Breastfeeding mothers need even more vitamin B2 than pregnant mothers. Some women need up to 50% more daily intake of riboflavin than they did before pregnancy. To provide for the hungry baby, breast milk absorbs much of the vitamin B2 than the mother ingests.
How do you know if you are riboflavin deficient?
Anemia, magenta (dry and red tongue), skin rash, dermatitis, dryness and cracking around mouth, nose and lips are all signs of riboflavin deficiency (2). If you are on a special diet due to lactose intolerant, vegetarian or anorexia, then you are at higher risk of riboflavin deficiency. (3)
What dietary sources contains vitamin B2?
The best sources of riboflavin are almond, mushrooms, wild rice, milk, yogurt, eggs, broccoli, brussels sprouts, spinach and whole grains. Flours and cereals are often fortified with riboflavin.
However, riboflavin can be destroyed by light. So food should be kept away from light to protect its riboflavin content. Although riboflavin is not destroyed by heat, it can be lost in water when foods are boiled or soak. The best way is to roast or steam the foods to preserve more riboflavin rather than frying or scalding your food.
Should you take a supplement?
YES - Although you can get enough riboflavin from a diet that includes grains, fairy products, meats, green vegetables and eggs, your doctor will advise you to take a prenatal supplements which provide the dietary reference intake (DRI) for riboflavin.
The recommended daily dietary intake for riboflavin (4)
• Women, 19 years and older: 1.1 mg (RDA)
• Pregnant women: 1.4 mg (RDA)
• Breastfeeding women: 1.6 mg (RDA)
What is Vitamin E
Vitamin E is an antioxidant. This means it protects body tissue from damage caused by substances called free radicals, which can harm cells, tissues, and organs. They are believed to play a role in certain conditions related to aging.
Vitamin E is also important in the formation of red blood cells and it helps the body use vitamin K. It also helps widen blood vessels and keep blood from clotting inside them. On top of that the body also needs vitamin E to help keep the immune system strong against viruses and bacteria.
In epidemiological studies, higher intakes of vitamin E have been related to reduction in cardiovascular disease, diabetic, certain cancers and cataracts. (1)
It is estimated that >90% of Americans do not consume sufficient dietary vitamin E, as α-tocopherol, to meet estimated average requirements. (2)
Deficiency of Vitamin E
Symptoms not very clear cut, but may include fatigue, inflamed varicose veins, wounds healing slowly, premature aging and sub-fertility, acne, anemia, muscle disease, dementia, cancers, gallstones, shortened red blood cell life span, spontaneous abortion (miscarriage), and uterine degeneration
Without sufficient E in the body, the essential fatty acids are altered so that blood cells break down and hemoglobin formation is impaired. Several amino acids cannot be utilized, and pituitary and adrenal glands reduce their level of functioning, iron absorption and hemoglobin formation are impaired.
The average diet today contains much less natural vitamin E than it did 50 years ago. This is partially due to lack of nutrients in the soil as well as use of farming pesticides.
Where is Vitamin E found?
Vitamin E is found in nuts, oils, vegetables, sunflower seeds, whole grains, spinach, oils, seeds, wheat oils, asparagus, avocado, beef, seafood, apples, carrots, celery, etc .
Vitamin E is lost in food processing which includes milling, cooking, freezing, long storage periods and when exposed to air. Vitamin E should not be taken together with inorganic iron supplements as it may destroy the vitamin, while organic iron, such as ferrous gluconate and ferrous fumarate does not affect the vitamin.
Vitamin E in Pregnancy:
Vitamin E is important for the development of your baby
1. Vitamin E for Baby's Brain Health
Vitamin E is critical to the early development of an embryo's nervous system. Part of the reason is because one of its function is to protect the Omega-3 fatty acids functioning, in particularly DHA and DHA is crucial for brain health
2. Development of Eyes and Head
When it comes to embryo nervous system development, one of the most important parts are the eyes and head. Correct amount (not too much of Vitamin E) will assist in healthy development
3. Stunting of Growth
Deficiency of Vitamin E during pregnancy can cause stunted growth
4. Improved cognitive function
Higher concentration of Vitamin E at birth has been associated with superior cognitive function at the age of 2 years old. (2)
How about supplements?
Look out for "d-alpha-tocopherol" on the list of ingredients - that means that the Vitamin E is from natural sources, whereas "dl-alpha-tocopherol" will indicate that it is synthetic.
Recommended daily intake
So what are the recommended daily intake of Vitamin E? For adults older than 18 years, pregnant women, and breastfeeding women, the maximum dose is 1,000 milligrams daily (or 1,500 IU).
2. Traber MG. Vitamin E inadequacy in humans: causes and consequences. Adv Nutr.
2014 Sep;5(5):503-14. Review.
Types of Vitamin A
There are 2 types of Vitamin A in the human diet:
- Preformed vitamin A (also called retinol) is used directly by the body and is found in animal products like eggs, milk, and liver.
- Provitamin A carotenoids are found in green leafy vegetables, orange/yellow-coloured fruit and vegetables like cabbage, carrot, lettuce, spinach, mango. By far the most important provitamin A carotenoid is beta-carotene (1)
What does Vitamin A do for you?
Vitamin A help preserve vision, fight infections, maintain healthy skin and bones, and regulate cell growth and division. Without enough vitamin A, you may be at a higher risk for night blindness or experience skin disorders or infections. It is also a key structural component in the development and maintenance of the heart, lungs, kidneys and other organs.
Vitamin A plays a critical role in:
- Maintaining body homeostasis
- Prevention of anemia
- Support pregnancy metabolism
- Pregnancy fetal development, especially bones, teeth, skin, and vision
So do you need to have good source of Vitamin A during pregnancy? The truth is developing babies need some Vitamin A. Vitamin A deficiency can lead to fetal and infant growth retardation. In fact, The World Health Organization (WHO) estimates that between 250,000 and 500,000 children are born blind every year. WHO also estimates that 13.8 million children have some degree of visual loss related to vitamin A deficiency.(2) If the pregnant mother don’t have enough Vitamin A in her body to start with, how would the fetal development be normal?
It is important to remember however that taking too much Vitamin A during pregnancy brings a small risk of birth defects, however too little Vitamin A brings risk of visual loss and growth retardation hence it will be extremely important to take a balance.
The Linus Pauling Institute states that “No increase in the risk of vitamin A-associated birth defects has been observed at doses of preformed vitamin A from supplements below 3,000 mcg/day (10,000 IU/day). Since a number of foods in the U.S. are fortified with preformed vitamin A, pregnant women should avoid multivitamin or prenatal supplements that contain more than 1,500 mcg (5,000 IU) of vitamin A. Vitamin A from beta-carotene is not known to increase the risk of birth defects.”
How much Vitamin A you need:
(RDAs for vitamin A are given as mcg of retinol activity equivalents (RAE) to account for the different bioactivities of retinol and provitamin A carotenoids)
Pregnant women age 18 and younger: 750 mcg RAE per day
Pregnant women age 19 and older: 770 micrograms RAE per day
Breastfeeding women age 18 and younger: 1,200 mcg RAE per day
Breastfeeding women age 19 and older: 1,300 mcg RAE per day
Nonpregnant women: 700 mcg RAE per day
You don't have to get the recommended amount of vitamin A every day. Instead, aim for that amount as an average over the course of a few days or a week.
2. Vision Disorders—Advances in Research and Treatment: 2012 Edition
Vitamin D is a very important vitamin for the baby's mother and baby. Mothers need to ensure their vitamin D levels are normal during pregnancy and while breastfeeding.
But first, what actually is vitamin D? It is a vitamin that is formed mainly in the skin and then altered in the body to a more active component. Most importantly, it is needed in every cell for the body to function properly!
Also known as the sunshine vitamin, 90% of vitamin D is made from sunlight exposure directly onto the skin. Women who do not get enough sun are observed to have low levels of vitamin D. The darker your skin, the more sun exposure one needs! So mothers need to expose themselves to sun to prevent getting low levels of Vitamin D or take a vitamin D supplementation.
Apart from that, a normal level of vitamin D is needed to absorb calcium from food. Calcium, which is vital for building strong bones, strong teeth and is important for the nervous system. Adequate levels are important for the immune system to work properly.
A recent study found that 1,500 to 2000IU of vitamin D daily had the greatest benefits in preventing preterm labour/births and infections. (1)
What happens if you don't?
Vitamin D deficiency is common during pregnancy. A newborn baby's vitamin D level is the same as its mother. If the mother has a low vitamin D level during pregnancy, then her baby too will be born with a low vitamin D level. There will be very little vitamin D contain in breast milk, so if the baby is vitamin D deficient, they will remain deficient while being breastfed. Because Vitamin D deficiency symptoms are generally less obvious, one might think they have sufficient amounts until getting a blood test!
Low levels of Vitamin D in children and adults have also been linked to the development of many illnesses.
Inadequate vitamin D can lead to abnormal bone growth, fractures or rickets in newborns! Because the bones don't form normally, the child can be short and the legs bowed. At times, when the calcium level in the blood is very low, it will lead to the child having seizures(fits). If you think this is 'kind of' rare, check out Dr Rangan Chatterjee's story on how his son had seizure because of being deficient in this simple vitamin. (2)
Vitamin D from food consumption alone is not enough!
Only 10% of food contain vitamin D naturally, so a lot are fortified with this vitamin. All milk are vitamin D fortified. The best way to really ensure adequate vitamin D is through supplementation.
1. Dawodu A, Akinbi H. Vitamin D nutrition in pregnancy: current opinion. International Journal of Women’s Health. 2013;5:333-343. doi:10.2147/IJWH.S34032.
I am a medical doctor and a researcher hence I believe in evidence based medicine. I was very shocked to find this article recently (by accident) titled " A Nutritional-Toxicological Assessment of Antarctic Krill Oil versus Fish Oil Dietary Supplements ". This article was published in 2014 in Nutrients Journal by researchers from Griffith University and CSIRO Food and Nutrition in Tasmania. This research is also funded by ARC Discovery Grant DP666891.
So here comes the shocking part. They actually tested multiple readily available fish oils on the market and found that the DHA content in particularly 2 products fell below (~10%–30%) the manufacturer specifications namely Nature’s Way Kidsmart (133 mg specified vs. 95 mg observed) and Blackmores Pregnancy and Breastfeeding Gold (125 mg specified vs. 85 mg observed).
When I shared this piece of article with my friends they asked me how could the manufacturers be so misleading and why is this even allowed? To be absolutely honest, I am not here to judge or comment on different brands but merely sharing what I found published in the medical research world.
The next table below is where the researchers did an analysis of the contamination level of all the products. Even though they found that none of the products analysed in the current study (at their highest recommended dosage) came close to fulfilling tolerable daily intake (TDI) levels for any single analyte, they have listed the top five products with the greatest contaminant burden for five key compound groups, plus TEQ values, ranking them from 1–5 with the sample containing the highest concentrations receiving a score of 5.
Bioceuticals Omegasure liquid fish oil and Blackmores 1000 mg both carried a cumulative score of 16, Blackmores Pregnancy and Breastfeeding Gold formula and Nature’s Own 1000 mg each received a score of 12.
According to the researchers, Blackmore’s Pregnancy and Breastfeeding Gold formula incorporates tuna oil, sourced from northern hemisphere oceans, thereby likely contributing to the higher contaminant burdens found in this formulation, despite its lower oil content.
This again highlights that translational research is very important. What is translational research? In a medical research context, it aims to "translate" findings in fundamental research into medical practice and meaningful health outcomes. It is very common in medical research where great amount of research work and funding has been put in but there is lack of dissemination of information to the public. This is a gap that needs to be bridged and my blog is all about this. In regards to this article, it was an accidental find for me, to better educate myself (and definitely to warn all my pregnant friends to not take the particular product mentioned) and the public.
The researchers in the article has concluded that ongoing monitoring of the pollutant content of fish and krill oil products will become increasingly important as food authorities seek
regulatory overview of this rapidly expanding industry.
Make sure you know what you are taking and whether you are really paying for the quality.
Bengtson Nash SM, Schlabach M, Nichols PD. A Nutritional-Toxicological Assessment of Antarctic Krill Oil versus Fish Oil Dietary Supplements. Nutrients. 2014;6(9):3382-3402. doi:10.3390/nu6093382.
I am back, after a long break. I have been extremely busy with sorting out other things in my life AND being part of a 12-week fitness challenge. Life has definitely not been easy. And...I am back to my obsession about Vitamin D. Found this particular study to be quite interesting. A longitudinal study published in Lancet in 2006 found that maternal Vitamin D status was associated with reduced whole-body and lumbar-spine bone-mineral content (BMC) in children that persists to age 9 years (1).
The study followed 198 children born in 1991-1992 in UK up to 9 years of age and results show that maternal vitamin D status during pregnancy and placental calcium transfer, as indicated by concentrations of umbilical-venous calcium, are significantly correlated with bone-mineral accrual at 9 years of age. The researchers also postulated that maternal vitamin D insufficiency during pregnancy leads to an impairment of placental calcium transport. It is known that the fetus accumulates about 30 g of calcium from the mother in utero, and 80% of this transfer occurs in the last trimester of pregnancy.
Furthermore, your baby's weight at 1 year predicts bone mass at later age (2). So do you all mothers-to-be out there understand the importance of Vitamin D in pregnancy?
1: Javaid MK, Crozier SR, Harvey NC, Gale CR, Dennison EM, Boucher BJ, Arden NK, Godfrey KM, Cooper C; Princess Anne Hospital Study Group. Maternal vitamin D status during pregnancy and childhood bone mass at age 9 years: a longitudinal study. Lancet. 2006 Jan 7;367(9504):36-43. Erratum in: Lancet. 2006 May 6;367(9521):1486.
2. Cooper C, Cawley M, Bhalla A, et al. Childhood growth, physical activity, and peak bone mass in women. J Bone Miner Res 1995; 10: 940–47
Yesterday a colleague of mine came to me and told me that his wife is 6 months pregnant and has a Vitamin D level of 15nmol/L and he continued by saying that the doctor suggested her to take 2 Vitamin D tablets a day from now on. I was literally in shock, with a Vitamin D level of 15nmol/L which is categorised as severe Vitamin D deficiency during pregnancy is rather serious and if the treating doctor had paid attention to any recent clinical guidelines, the dosage suggested would have been more than just 2 Vitamin D tablets (2000IU of Vitamin D supplementation).
Have a look at the clinical guidelines for Vitamin D deficiency above which is taken from King Edward Memorial Women's Hospital in Perth, WA, Australia. They actually recommend taking 5000IU of Vitamin D plus calcium for 6 weeks if Vitamin D level is below 50nmol/L. It makes me wonder how can a treating doctor be so out of date with the current treatment plan and why didn't he/she highlight the importance of maintaining optimum Vitamin D level in pregnancy?
Interestingly, my colleague's wife has actually been taking a certain brand of Vitamin D supplementation ever since she found out that she was pregnant. All I have to say is maybe that brand is pretty low quality. If you would like to know further details, please email me.
Effects of low maternal Vitamin D includes:
- Low serum calcium in newborns, with or without convulsions
- Defective tooth enamel
- Lower birth rates and higher risk of small for gestational age
- Lower newborn bone mineral
- Affects fetal femoral bone development
- Greater risk for multiple sclerosis, cancer, insulin dependent diabetes mellitus, and schizophrenia in later life
Population that should be screened for Vitamin D deficiency:
- Dark skin population
- Have limited exposure to sunlight (tend to be indoors/ protected from sun when outdoors)
- Pre-pregnancy BMI > 40
I cannot stress enough the importance of Vitamin D and how common it is to find a person who is deficient in Vitamin D these days due to the risks of developing skin cancers with extreme sun exposures. In fact, a few of my close friends who are taking multivitamins think that there is enough Vitamin D supplementation in it! To be honest most multivitamins consist of minute amount of Vitamin D and it is not enough for good Vitamin D level maintenance.
The take home note, each and every pregnant woman should know their Vitamin D levels and understand the importance of maintaining the level throughout pregnancy.
A latest news reported by The Age has confirmed a case of Zika Virus in a pregnant Victorian women after returning from overseas. It is not revealed which country she travelled to as to protect her privacy. However health professionals are advising women who are pregnant or wish to get pregnant to consider postponing travelling to any country with active Zika virus transmission.
According to ABC News Australia, Victoria's Health Department has released a health alert urging Victorians to "get access to good quality information" before travelling to countries where there was a Zika prevalence. The virus has been identified in 25 countries and currently have active transmission in Brazil and other parts of Central and South America.
On top of that according to Victoria's acting Chief Health Officer Roscoe Taylor, Zika Virus could also be sexually transmitted other than being transmitted by mosquitoes.
Symptoms of Zika Virus can include a fever, a rash which is sometimes itchy, and joint pains. However it is important to note that 80% of the time there might not be symptom at all. Hence, pregnant who have travelled to high risk Zika Virus areas and have symptoms should seek their GP for testing.
My heart goes out to pregnant women diagnosed with Zika Virus, it is truly an extremely stressful and anxious period for these women not knowing whether their unborn child is affected.
I've came across quite a few cases of obese patients who would really like to get pregnant and have read a fair share of pregnancy journey stories on various pregnancy forums. Even though most IVF centres have a 35 BMI cut off line, personally I believe losing weight is a number one priority if you wish to get pregnant and are on the higher side of the BMI. The reason is simple, in order to have a healthy baby, you should be healthy first and to me a BMI of more than 30 is definitely not healthy.
Obesity is associated to a variety of endocrine abnormalities that might lead to chronic anovulation in women. Progesterone on the other hand is an extremely important hormone in supporting the implantation of a fertilized egg in the uterus as well as help maintain a pregnancy by preventing menstruation. To have a successful pregnancy, progesterone levels should maintain high and sustained throughout the pregnancy. Failure to keep progesterone level high will result in miscarriage.
In this study of 30 anovulatory obese patients between 18 and 35 years old without any thyroid disease, researchers found that with the mean weight loss of 9.5 kg, which represents a weight loss of 10.96% from initial body weight, 26 patients (86.6%) resumed spontaneous ovulation (1). The results demonstrated that with a small weight reduction and a decrease in total body fat percentage, it will improve the hormonal profile and restore ovulation in anovulatory obese women. Thus weight loss should be considered before starting with ovulation induction therapy.
In a more recent study in Singapore, researchers investigated the association between maternal body mass index (BMI) and serum progesterone level in first trimester singleton pregnancies for 194 women at a tertiary maternity hospital in Singapore, from January 2012 to February 2014. Obesity (maternal BMI ≥30 kg/m2) has an increased risk for serum progesterone <35 nmol/L. Results indicate that maternal obesity is associated with low first trimester serum progesterone.
In conclusion, pre-pregnancy weight optimization is beneficial in regulation of serum progesterone level and maintenance of healthy pregnancy.
1: Hernández García IA, Gutiérrez Gutiérrez AM, Gallardo Lozano E. [Effect of weight reduction on the clinical and hormonal condition of obese anovulatory women]. Ginecol Obstet Mex. 1999 Sep;67:433-7. Spanish. PubMed PMID: 10544539.
2. Goh JY, He S, Allen JC, Malhotra R, Tan TC. Maternal obesity is associated with a low serum progesterone level in early pregnancy. Horm Mol Biol Clin Investig. 2016 Jan 9. pii:/j/hmbci.ahead-of-print/hmbci-2015-0030/hmbci-2015-0030.xml. doi:10.1515/hmbci-2015-0030. [Epub ahead of print] PubMed PMID: 26751901
Omega-3 remains one of the most researched nutrition in pregnancy. Omega-3 contains eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA) which are uniquely important for our human body. While omega-3 has multiple benefits, from slowing ageing to aiding depression as highlighted in my blog earlier, one should not overlook its usage in pregnancy.
Preterm birth also known as premature birth whereby a baby is delivered before 37 weeks of gestation continues to be the one of the leading causes of infant deaths worldwide. Every year an estimated 15 million babies are delivered preterm. Results from a systemic review published in European Journal of Obstetrics & Gynecology and Reproductive Biology has shown that Omega-3 fatty acids are effective in preventing early and any preterm delivery. They also concluded that this intervention is simple and easily available and has the potential to influence population based strategies in the prevention of preterm birth (1).
Omega-3 fatty acids have also been shown to decrease incidence of pre-eclampsia (disorder of pregnancy characterized by high blood pressure and a large amount of protein in the urine), increase birth weight and aid in postpartum depression. American Pregnancy Association suggests 300mg DHA (docosahexaenoic acid) daily for pregnant and lactating women.
It is well known that the best sources of omega-3 fatty acids are cold water fish such as salmon, tuna, sardines, anchovies, and herring. But in terms of pregnancy, many people are justifiably concerned about mercury and other toxins in fish. For this reason, purified fish oil supplements are often the safest source of EPA and DHA.
1: Kar S, Wong M, Rogozinska E, Thangaratinam S. Effects of omega-3 fatty acids in prevention of early preterm delivery: a systematic review and meta-analysis of randomized studies. Eur J Obstet Gynecol Reprod Biol. 2015 Nov 30;198:40-46. doi:10.1016/j.ejogrb.2015.11.033. [Epub ahead of print] PubMed PMID: 26773247.
Dr Nicole Ng (MBBS) is a medical doctor with a passion in women's health and medical research