Prenatal Vitamins: A Common Sense Guide
If you know two things about me, know this: I love M&Ms (too much) and I am the father of 4, 3 of those being triplets. Being a dad is the best thing about my life.
Here’s the triplets when they were born being held by my wife:
Here’s the full goon squad now:
I know a thing or two about prenatal support.
So what does a holistic pharmacist do to help support his wife’s pregnancy nutritionally? What prenatal multivitamins are best for such an intense pregnancy? The answer is, the same as everyone else, except a little bit more.
This article will help anyone who is, wants to be, or has been pregnant get to the bottom of what is real and what isn’t around prenatal vitamins.
We all want what’s best for our kids, even before they arrive and drain all our resources and youth and energy. Doing what’s best may require more than a “1 a day” but it does not have to cost as much as premium supplements do.
This is a comprehensive walkthrough of this topic, covering misconceptions around prenatal vitamins (especially quality), what the key nutrients are that a pregnant woman requires, how the Vital 5 is framed especially for pregnant women, and finally, our recommendations for a prenatal vitamin regimen.
NOTE: This is meant to be a comprehensive discussion. I’m not trying to confuse anyone or make it more complex, I just want to lay out all the options so YOU can make the best decision and not believe the BS out there.
All the way at the bottom, right before I sign off, I’ve included what I recommend, both professionally and what I’ve given my wife and have recommended to all the women in my personal life who have gotten pregnant. That advice has not changed in 10 years, as I believe this regimen is the best of the best!
Changing The Prenatal Vitamin Paradigm
The first step to getting the best prenatal vitamin is addressing our mindset around prenatal vitamins. Let’s separate fact from fiction:
Most women don’t even need prenatal vitamins. Yup, I’m saying it. A recent UK study published in Drug and Therapeutics Bulletin found most well-nourished (an actually a low bar in the world of population-based nutrition) women derive no benefit from the vitamin component of their prenatal vitamin.
The only thing women NEED when it comes to prenatal nutrition is folic acid, especially in the early weeks of pregnancy. Most foods are fortified with folic acid because not everyone has access to multivitamins, so even without trying most people are getting all the nutrients a prenatal vitamin could give them.
One a day prenatal vitamins won’t really happen. I mean, a one a day multivitamin marketed towards pregnancy that has a little extra iron and folic acid that meets the basic needs of most women DEFINITELY can happen.
The purpose of prenatal vitamins, though, is to supplement nutrients needed to make mom and baby healthiest, and a single pill of isolated vitamins only covers the bare minimum, and as we said just a moment ago, most of us don’t need bare minimum.
It’s not really a whole food prenatal. The same vitamin tricks we’ve covered in Garden of Lies about raw, whole food, and a general misrepresentation is 100% in play here. Literally all vitamins marketed as prenatal whole food supplements are not whole food anything.
Your prenatal vitamin that says it’s giving you everything under the sun, like fish oil, isn’t delivering the doses of these ingredients you really need. Supplement companies hope you only read the front (the marketing) and ignore or don’t know how to read the Supplement Facts Panel (the truth). We’ll cover this in more detail later.
Supplements can be gross. Most moms are going to be amazingly cautious about anything they put into their baby’s bodies. This is a natural thing to do - to be skeptical and concerned about products. This extends (very unnecessarily) to vaccines, and even if you are not in the anti-vaxx crowd, you still may have heard enough “doubt” to give you pause.
Without launching into that funky world, I just want to have moms have MORE of a Spidey-sense/Peter-tingle about the quality of the supplements they themselves are using than they would about that or any of the other “chemicals” they are concerned with.
We throw blind faith in the natural products industry, but the products are often not natural and because of the Food and Drug Administration rules and the regulatory environment, they can contain heavy metals, adulterants, contaminants, and more. I’ve seen moms talk about giving their children the best, but the prenatal vitamins they’re using for their current pregnancy fail third-party testing for contamination.
Separate out a “prenatal vitamin” from prenatal nutrition. A prenatal vitamin, as pointed out by many of these, is just a simple multivitamin with added folic acid and maybe a little extra nudge on a few other isolated vitamins or minerals. You need more than that.
The Prenatal Formula
There’s a simple way I explain what nutrition is needed during pregnancy to help future moms better understand what kind of product(s) they should be looking for:
Prenatal Care = Nutrition for Any Woman + Added Requirements for Pregnancy
The concept of any one prenatal vitamin solving all the nutrition requirements for women generally or pregnant women should be thrown far out the window.
It will take multiple types of supplements to truly address all doses of nutrients you need while pregnant. It doesn’t have to break the bank, but I will show you some math that may help you understand how the costs add up.
What A Pregnant Woman Requires
If we can take a step back for a moment from the concept of “needing a prenatal vitamin” and just discuss the unique nutritional needs that a pregnancy requires, we can reframe the discussion to best achieve our goals.
In its simplest, a pregnant woman is a woman who is pregnant. Deep stuff. I say this because we’ve already covered the nutritional and basic supplement needs of humans in our discussion of the Wellness Pyramid and Vital 5, women being one subtype of those humans.
The Vital 5 nutrients for omnivores and vegans talk about the need of great diet and 5 crucial nutrients that even the best diet is lacking. A woman, pregnant or not, would benefit from these nutrients:
The Vital 5 Nutrients
- Calcium & Bone Health Nutrients
- Micronutrients (aka multivitamins when needed).
In simplistic terms, pregnancy is just normal life with a “little” added need. Those unique added needs are:
- Folic Acid - Needed early in the pregnancy (if not before conception) to help prevent neural tube defects
- Vitamin D - Vitamin D requirements increase during pregnancy from 1000 IU to 2000 IU daily by most experts’ recommendations
- Iron - Changes in blood volume can cause anemia and some data shows taking extra iron supplements can help with preeclampsia
These unique nutrients are in addition to a diet nourishing enough for mom and baby. This means accounting for additional caloric needs and macronutrients. We’ve discussed nutrition in our Dietary Jenga article plus a million places elsewhere, so we won’t rehash that here. Instead, we’ll stress what’s most important.
Your calorie requirements will increase, but only by about 300 extra calories a day in the 2nd and 3rd trimester. Your protein requirements will increase, and experts recommend a non-weight based number of 75-100g, but some taller or heavier women may need that anyway. The big takeaway: eat more, ensure you are getting your normal daily requirements for a healthy diet, then add more due to the pregnancy, especially protein.
To best nourish your body for pregnancy, a woman must eat well to meet increased macro and micronutrient goals. Use supplements only when necessary to meet these goals, not in place of good nutrition.
The Vital 5 For Pregnancy
Using the Vital 5 as our guide, I’ll reframe the nutritional needs into which supplements you should be getting. We’ll start in reverse order.
Multivitamins: The “Vitamin” Part of The Prenatal Vitamin
What you need: You need to ensure you are getting all the micronutrients a good diet will give you, so you look to a multivitamin to cover the bases, A-Z, just in case your diet isn’t perfect every day. On top of this, you need additional Folic Acid (folate) and Iron.
What you should know: Most multivitamins are posers. They aren’t what they say they are. They are synthetic isolated vitamins that are in forms that aren’t the most absorbable, often with wonky doses. As we discussed in numerous articles, but most recently in Garden of Lies. Some even dress up and pretend they’re whole food, but they really aren’t .
We generally take pause around multivitamins, citing it to be a craze meant to sell stuff, not to give you any benefit, and we’ve encouraged people to Throw Away Their Multivitamins.
Who wants to risk it during pregnancy, though, right? So just take the supplement, but make sure you’re getting what’s needed. It’s a good idea to use the supplement, so do it.
What you want: Look for a true whole food multivitamin if you can. If not, make sure you’re using a multivitamin with the right doses and more absorbable forms of nutrients. A targeted “prenatal” isn’t necessary if you are getting the “pregnancy nutrients” folic acid, Vitamin D, etc.
An aside: I know we are advocates of real whole food vitamins whenever possible. Isolate vitamins are fine during pregnancy. This isn’t a forever thing, you’re taking them to hedge your bets, plus it’s easy to see on the label how much you are getting.
True whole food vitamins won’t list out how many mg of each ingredient there are. If we are to use a traditional multivitamin (isolates, not food), let’s just make sure we’re getting the best forms of those vitamins.
Continuing in the Vital 5 category we call micronutrients, we need to ensure we’re getting enough folic acid (folate) and iron. Folic acid is the most important part of a prenatal supplement. Folic acid is used to prevent birth defects. Some may argue that all you REALLY need is a good diet and additional folic acid while pregnant.
What you need: Most experts recommend getting 800 mcg of folic acid a day and 27mg of additional iron.
What you should know: There’s a big push towards people using folate instead of folic acid. We covered the difference in our MTHFR article, but essentially folate is the naturally occurring form and is utilized in our body easier than folic acid. I recommend people look for l-methylfolate.
On the iron side of things, make sure you are getting an iron that won’t make life miserable via constipation. We recommend chelated minerals as you’ll absorb more and have less chance of GI side effects.
What you want: Use l-methylfolate at whatever dose your doc recommends. Some like 800mcg (2 of these) or some like 1000mcg (1mg, which is this one). For iron, skip the ferrous sulfate and look for real iron chelates like Easy Iron.
Studies have shown a diet rich in Omega-3 will be good for brain health, eye health, joint health, heart health, mood support and more. Good fats help brain development in the little bubbas, so that’s quite important!
The problem is, most of us don’t eat a big serving of fish every day to balance out the Omega-6:Omega-3 ratio that’s out of whack from our wack diets. See The Guide To Dietary Fats article for more.
What you need: Most of us need about 3000mg of EPA and DHA to re-establish the Omega-6:Omega-3 target ratio of 4:1. Most studies and analyses agree: doses that most people take are ineffective at impacting health, but when doses are higher, better results are seen.
What you should know: Most prenatal vitamins that include Omega-3 are using super-low doses. If your target is 3000mg, most supplements are providing at most 1/6th of your requirements. There’s lots of concerns with quality in fish oil, so getting a supplement free of heavy metals, PCBs, dioxins, and one that isn’t rancid is a bit more challenging than you’d hope.
The other thing to know is that taking a properly dosed fish oil will increase your monthly cost of prenatals. A well constructed prenatal regimen is typically a minimal monthly cost (we’ll show you the math below), but adding high dose fish oil will ramp those numbers up quick. In pregnancy, I’m kinda ok with the “something is better than nothing” mentality, but I pushed my wife to get the correct doses and I’d do the same for my patients.
What you want: Shoot for 3000mg of EPA and DHA intake in a day, primarily from food If you can’t get enough, then add a high potency Omega-3. You might be taste-sensitive, so try to avoid liquids.
Calcium, Vitamin D, and Bone Health
Optimizing bone density is critical, especially during ages 18-30, the typical child-bearing years. After age 30, our bones will be on a downward trend, so beefing up before then is priority 1.
Vitamin D doesn’t have official high dose recommendations from groups like the NIH, but most experts agree that they’re needed.
What you need: Calcium recommendations are between 1000mg-1300mg a day for pregnancy, but most of us don’t get nearly enough. Vitamin D is officially recommended at 600 IU for pregnancy, but many experts agree that 2000 IU is best, especially during the 2nd and 3rd trimester.
What you should know: Calcium is a mineral, so the form matters. As we covered in Calcium Doesn’t Work, skip calcium carbonate and citrate, and focus on hydroxyapatite (MCHA) to get the best bioavailability.
Only supplement what you aren’t getting in your diet, so do some math to prevent over-doing it. Most of us get 400mg of calcium easily in our diets, so you’d only need 600-900mg daily additionally.
The amount of calcium in most prenatal vitamins is insanely low.
Vitamin D is best in a liquid form, so use softgels or liquids only. Prenatals where the vitamin D is mixed in the powder is less than ideal. We covered more Vitamin D tips in our mini-video series.
Protein is a macronutrient found in healthy foods. You should get 100+% from your diet, no questions asked. Some, like people over 50, vegetarians, or vegans, can struggle to hit protein goals. Protein supplementation is needed, and we covered this in our Protein: Whey’ing the Pro’s and Cons article and our conversation around Collagen.
I really don’t like to see women using protein supplements during pregnancy. Eat up! This is the one time in your life where you can really go nuts, so do so by eating lots of healthy foods.
What you need: Protein requirements for women are about 1 gram for every kilogram of body weight (divide pounds by 2.2). General advice says pregnant women should shoot for 75-100g. That’s great, except if you are tall! Whatever your daily requirements are, shoot for more, and check with your OB to see what they recommend.
What you should know: Protein supplements are gross. Shake powders are commonly contaminated with lead or arsenic (especially plant proteins). Sometimes the protein is so over-processed they have to spike it with non-absorbable isolated amino acids just to pass basic testing. Get protein from your diet.
We are mostly bacteria. Not an exaggeration, as there is 10x the amount of bacterial DNA in us than there is human DNA. Your microbiome is an important thing to nourish and protect. You bet your hormones and that little succubus is going to alter it.
What you need: Most of us would benefit from a well made Probiotic. We have a few bits at our Probiotic Buying Guide.
What you should know: Probiotics is where the natural products industry shows their true colors. They can’t even make vitamins cleanly, now they’re going to make a product that is alive, reproducing, AND have it survive the GI tract AND colonize to give a health benefit. I mean, some recommend bacteria from the dirt, and some products have contaminant strains that are harmful to humans. Be careful!
What you want: To keep life simple! Temperature stable, properly dosed specific, and well-researched strains. We make it easy with Probiotic Complete.
BIG NOTE: When someone comes to me about a prenatal regimen, I normally don’t include Iron, Calcium, Protein, or Probiotics, unless they’re looking for 100% optimization and we’re sure we need extra iron. I don’t want to constipate anyone!
Instead, I focus on the Multivitamin, Folic Acid, Vitamin D, and Omega-3 fatty acid supplements.
Let’s talk about our actual recommendations now!
The 3 Types of Prenatal Vitamin Regimens
It’s your world, squirrel. I think we’ve stressed enough that there are a lot of different options or paths for what kind of prenatal regimen you COULD get. I’ll lay out what I believe the 3 paths are.
Regimen 1: Folic Acid Only
Most don’t need multi, especially if you are well-nourished. Add 800mcg of folic acid to a healthy diet, especially pre-conception, and you’ve gotten off dirt cheap.
- Pros: Simple, cheap, few pills
- Cons: Not guaranteeing other nutrients are being received consistently.
- Methylfolate 400mcg per tablet. Cost per day (2 pills): 32 cents
- L-methylfolate 1mg (1000mcg) per capsule. Cost per day (1 pill): 30 cents
Regimen 2: A Traditional Vitamin Targeted Towards Pregnancy.
This is a regular multivitamin that has added folic acid and maybe extra iron, Vitamin D, or calcium. Sometimes they’ll add fish oil, but it definitely won’t be near the dose.
- Pros: Simple, few pills, more comprehensive vitamin intake
- Cons: Amounts of other nutrients may not be at target doses, forms of nutrients may not be most absorbable and can contribute to GI side effects. This should be cheap, but many are often over charged for these products.
- Prenatal Complete 1 packet daily. Cost per day: $1.99
NOTE: You’ll need to supplement additional Omega-3 fatty acids to hit target doses, just like with all prenatal supplements.
Regimen 3: A Comprehensive Supplement Regimen With Added Pregnancy Support.
This is the Vital 5 for women with added, proper doses and forms of things like Vitamin D, Calcium, Omega-3, and more. This is certainly no one a day, but closer to 6 a day, minimally.
- Pros: The no-BS way to get all of the recommended nutrients.
- Cons: Lots of pills, high dose fish oil adds to the cost, making this a more expensive option if the fish oil is kept on board.
- Whole Food Multi (4 daily) + L-Methylfolate 1mg (1 daily) + Vitamin D 2000 IU (1 daily) + Alaskan Omega 900 (3 daily). Cost Per Day: 64 cents + 30 cents + 7 cents + $1.25 = $2.26 per day
- Coenzyme Multi (2 daily) + L-Methylfolate 1mg (1 daily) + Vitamin D 2000 IU (1 daily) + Alaskan Omega 900 (3 daily). Cost Per Day: 36 cents + 30 cents + 7 cents + $1.25 = $1.98 per day
As you can see, the vitamin regimen is inexpensive daily, but the fish oil adds a significant cost.
Our Recommendations For Prenatal Vitamins (What I Gave My Wife)
As a papa of triplets + a singleton, we understand very well the increased nutritional needs during pregnancy. A litter of children is a pretty extreme representation of what a typical pregnancy needs, to say the least.
Here’s what we’ve used in my house for our two pregnancies:
- Whole Food Multi - 2-4 daily
- L-Methylfolate 1mg - 1 daily
- Vitamin D 2000 IU - 1 daily
- Alaskan Omega 900 - 3 daily
Erin did need extra iron, so she used a chelated iron like Easy Iron. Protein and calcium came from a healthy diet that she didn’t mind eating at all. She was hungry!
Reviewing the costs, I don’t believe $2 a day is too much for high dose, high-quality comprehensive supplements. If it was, we could simply cut the Omega-3 and half our costs while still getting the best of all the other nutrients.
Simple, But Not Easy
If I may do a mini-rant here… There are people all over the world in all sorts of varied economic, nutritional, and social statuses having babies successfully. We get a bit obsessed over perfecting nutrition to have our sweet little blood-sucking vampires be the best possible versions. I feel that pressure starts with the natural products industry as propaganda with the end result of expensive consults with “nutritionists” or “practitioners” and a complicated, expensive regimen.
To conclude that rant, I recommend watching the documentary “Babies,” which shows pregnancy, birth, and child rearing in different areas of the globe. It helped us gain a more grounded perspective, even with having triplets.
For prenatal vitamins, my advice is the same as it ever was and is the same as it is for all of the vitamin space: supplement what you need with the fewest, highest quality products that give you the right dose and form of a nutrient.
If you choose to use prenatal vitamins (you should), start taking prenatal vitamins early - even before conception.
Don’t believe the hype, don’t stress too much, and know that the healthiest, best choices do exist. You are probably already making them.
Just trying to keep it real...
Neal Smoller, PharmD
Owner, Pharmacist, Big Mouth