Essential nutrients for women prior to conception

Calcium

The recommended daily intake of calcium prior to conception is 1000-1300mg, increasing to 1500 to 2000mg during pregnancy. To ensure your levels of calcium are adequate it is essential to eliminate factors that will interfere with calcium absorption, including caffeine, alcohol and smoking. Adequate intake of the minerals magnesium, boron, and vitamin D are also essential for optimal absorption of calcium.  Weight bearing or resistance exercise will help to improve calcium absorption.

While dairy products are a great source of calcium, the process of homogenizing milk depletes the enzymes required for calcium absorption. Make sure your diet includes at least one serving of green leafy vegetables, nuts and seeds. Combining this with an adequate intake of organic dairy products will help to boost your levels of calcium.

Calcium supplementation during pregnancy reduces the risk of pre-eclampsia and high blood pressure by half, so supplementation is essential for those with low dietary calcium intake, dairy allergies or intolerance or women with existing risk factors for hypertensive disordersⁱ.

Magnesium

Magnesium is essential for the production of estrogen and progesterone, the function of the nervous system, utilization of B vitamins, and for energy production.

The use of phosphates in farming reduces the bioavailability of magnesium, and the CSIRO estimates that due to deficiencies in the soil over 70% of Australians are deficient in this essential mineral.

Women with Premenstrual tension (PMT) or cramping with periods, have low serum magnesium levels and supplementation improves these symptoms.
Magnesium is vital for the nervous system and for relaxation.  A magnesium deficiency leads to nervous tension and irritability which in turn leads to overproduction of the adrenal hormone cortisol.  Cortisol increases magnesium excretion and inhibits its absorption.  Overproduction of cortisol also interferes with healthy production of estrogen and progesterone.

Saturated fats interfere with magnesium absorption from foods and alcohol consumption increases your need for magnesium supplementation. Women taking the oral contraceptive pill are commonly deficient in many vitamins and minerals including Magnesium.

Food sources of magnesium include whole grains, dry beans (especially soya), nuts, bananas, kelp, wheat bran, wheat germ and dark green leafy vegetables. However if the soil is low in magnesium, then these foods will not provide enough magnesium for good health.

Chocolate is a rich source of magnesium. While this isn’t the best source of magnesium, chocolate cravings can indicate a magnesium deficiency and supplementing magnesium may stop the cravings.  PMS, Mood Swings, Chocolate and sugar cravings, and cramping can indicate a need for more dietary magnesium or supplementation.

Zinc

Zinc is perhaps the most important nutrient for female and male fertility and hormonal health. Zinc is needed for pituitary functioning, normal growth, cell division and tissue repair.

Zinc has an important role as an enzyme in DNA transcription and protein synthesis.  DNA is a major part of germ cell (ovum and sperm) development.  This is why zinc is so important for reproduction.  Zinc also has an important function as an antioxidant.  Zinc deficiency leads to oxidative damage of protein, lipids and DNA and decreases the absorption and metabolism of dietary folate.ⁱⁱ

In females, zinc deficiency leads to reduced interest in sex and abnormal menstrual cycles. Zinc can be particularly lacking in those who take the contraceptive pill. A deficiency is often indicated by white banning in the nails. Absorption of this mineral is problematic, as it has an antagonistic relationship with many other nutrients, especially iron and some foods including dairy produce. Zinc supplements should be taken on an empty stomach, away from foods or other supplements (last thing at night may be the easiest time).

Food sources of zinc include; whole grains, wheat germ, nuts, seafood (especially oysters), meat, milk, green vegetables, mushrooms, onions, root ginger, egg yolk, seeds and herbs. However even these foods (with the exception of oysters) are not particularly rich in zinc.  Refined foods, alcohol, sugar and caffeine will strip the zinc from your body’s reserves. Zinc supplementation is required for most people to ensure adequate levels.

Iron

Iron deficiency is the most common mineral deficiency affecting menstruating women.  Anemia is the most severe form of iron deficiency, resulting in weakness and shortness of breath.  Symptoms associated with iron deficiency include; fatigue, teariness, immune deficiency, vertigo, poor concentration and fatigue and heavy menstrual bleeding.  Vegetarians and women who consume little red meat need to be conscious of combining foods to maximize iron absorption.
If you have marginal levels of iron, as many women do, this can, paradoxically lead to heavier periods and clotting, or it can inhibit menstrual flow.

Iron deficiency anaemia during pregnancy has been associated with an increased risk of low birth weight, preterm delivery and perinatal mortality. In addition, there may be an association between maternal iron deficiency anaemia and postpartum depression, with poor results in mental and psychomotor performance testing in the child.

During early pregnancy, iron is rapidly mobilized from the tissue stores. This process is reflected by a decrease in ferritin levels (stored iron) from a normal value of 60ng/ml to 15ng/ml.  Iron is being mobilized to expand the blood volume of the mother and to produce placental and fetal tissue.  It is important prior to conception to ensure that ferritin levels are normal.

You should only take iron supplements when a blood test shows low iron levels or low ferritin (the stored form of iron). Iron should be taken in conjunction with a comprehensive range of other nutrients including folate, B12 and vitamin C to encourage absorption. In excess, iron is toxic and some iron supplements may cause constipation.

Iron absorption is a complex process. Phytates from whole grain cereals such as wheat, rice, maize, millet, barley and oats can inhibit iron absorption.  Food sources of iron include kelp, lean meat, dried fruits, dried beans, wheat germ and bran, nuts, seeds, herbs such as parsley, yeast, nettle and red raspberry teas and green leafy vegetables.

Iodine

Iodine is an essential mineral for the healthy functioning of the thyroid, which is crucial for healthy hormonal balance. Iodine is considered the most variable mineral in soil, influenced by fertilizers and local geography.  The use of phosphates in food reduces iodine. Current evidence shows that Australians have a mild deficiency of iodine.

Around 50% of pregnant women in Australia have insufficient iodine.  Iodine is essential for healthy brain development and normal growth in the foetus.  A deficiency during pregnancy can lead to cretinism in the child. Cretinism is a disease causing mental retardation.

Iodine must be increased during gestation to 200-300µg/day to support the maternal and foetal thyroid function, and to compensate for the enhanced urinary iodide excretion. Having iodine levels tested is recommended. Low iodine (below 50µg/day) levels can be increased through taking a supplement.

The most bioavailable form of iodine is found in the sea from salts, kelp and seafood.  Goitrogens are toxic chemicals found in the brassica (cabbage) family and soy products that interfere with iodine utilization and thyroid hormone production.

Selenium

Selenium is a trace mineral and antioxidant.  In the body selenium forms proteins known as ‘selenoprotiens’ which function as enzymes.  A selenium deficiency is associated with reduced levels of germ cells (pre-sperm cells) and reduced fertility.ⁱⁱⁱ

The recommended daily intake (RDA) for selenium increases during pregnancy from 55-60µg to 100µg/day, presumably for foetal growth, which manifests as decreasing maternal blood and tissue selenium concentrations. Pregnant women with gestational or pre-existing diabetes also have greater decreases in selenium concentration. Studies have reported an association between maternal serum selenium deficiency and neural tube defects, sudden infant death, and first trimester miscarriages.

High doses (especially of the forms sodium selenite or selenate) can be toxic, so keep to the recommended levels (currently 200mcg). Some forms of selenium are rendered ineffective if taken at the same time as zinc or vitamin C. Selenomethionine is the preferred, most effective, form which is stable and can be taken with other nutrients.

Garlic, onion, butter, wheat germ, Brazil nuts, seafood (but not in large amounts, even in these foods) contain selenium. Unfortunately the soil in Australia is very low in selenium, a problem which is compounded by the fact that only small amounts are available in most non-prescription supplements.

Chromium

This mineral works with manganese and the B vitamins to control sugar cravings and low blood-sugar levels, which can be a problem premenstrually. Chromium is not easily absorbed, and is also leached from your body’s stores when you eat refined grains, sugar, or drink alcohol.

Food sources of chromium include brewers yeast (not for Candida sufferers), liver (organic only), beef, chicken, haddock, whole grains, milk.

Choline

The availability of choline for normal development of the foetal brain is vital. The mother’s dietary choline influences the rate of birth and death of nerve cells in the memory centre (hippocampus) of the brain. Choline is also required for normal neural tube closure in early pregnancy and is also important for maintaining normal plasma homocysteine concentrations during pregnancy. High maternal homocysteine concentrations are associated with increased incidence of birth defects. Studies show that during pregnancy and lactation, maternal reserves of choline are depleted due to the transport of choline from mother to foetus across the placenta. A lack of cholin in a mother’s diet at this time may have life-long effects on her child.

Vitamin A or betacarotene

Vitamin A is  required for growth, cellular differentiation, and normal foetal development during pregnancy. Despite its importance, this vitamin can be toxic when taken in excess and may cause deformity when taken in high doses shortly after, before or during early pregnancy. Several cases of adverse pregnancy outcomes have been associated with ingestion of 25 000IU (7500RE) or more per day of vitamin A.

Betacarotene is a natural source of vitamin A. Adequate levels of vitamin A and betacarotene can be obtained through green leafy vegetables, red and orange vegetables and red salmon.

Vitamin B6

B6 is particularly important to relieve premenstrual fluid retention and sore breasts. B6 may increase progesterone levels and inhibit excessive prolactin production by the pituitary gland.  B6 encourages the absorption of zinc, and is crucial to normal brain function and stable mood.

Oral contraceptives, coffee, alcohol, smoking and stress all increase your need for the B vitamins, and sugar leaches them from your body, as do all refined carbohydrates.

Folic acid

Folic acid is essential for DNA synthesis and repair, and is required for early embryonic development.^iv According to researchers, the folic acid requirements are contained within the sperm and ovum at the time of fertilization.^v  This is why it is imperative to take folic acid supplements for a minimum of six months prior to conception.  Poor folate status one month prior to conception and/or during the first trimester of pregnancy is a risk factor for neural tube defects in the newborn.  One study suggested the risk of neural tube defects in newborns from a folate deprived diet is 10 fold higher than when dietry folate intake is adequate. The recommended daily intake of folate in a preconception diet is between 500ug-4mg per day.

In Assisted Reproduction, women taking folic acid had better quality oocytes and a higher degree of mature oocytes compared with women who did not take folic acid supplementation.^vi Low folate levels have been linked to miscarriage.^vii
Long term use of the oral contraceptive pill induces folate deficiency, and can deplete  other B vitamins in the body. A deficiency may result in hyperhomocysteinemia.  This is why after ceasing oral contraception it is important to allow 4 months to restore B vitamins and folate levels in the body before conception.

HoMocysteine and folic acid intake

Hyperhomocystieinemia is an inflammatory condition results in poor reproductive performance in both men and women. It also increases the risk of birth defects, gestational diabetes, preterm delivery, poor foetal growth and preeclampsia during pregnancy. Homocysteine is elevated in women with Polycystic Ovarian Syndrome.

Homocysteine levels are increased by aging, low vitamin intake, smoking, coffee, some diseases and various drugs.  A standard fasting blood test can be used to determine homocysteine levels.  To reduce excess homocysteine the presence of the nutrients; betaine, zinc, choline, folic acid, vitamin B9, vitamin B12 and particularly vitamin B6 are crucial. Betaine can be obtained from silverbeet and spinach.

Vitamin C

This vitamin helps to strengthen blood capillaries and to alleviate heavy periods and premenstrual depression.  Vitamin C is also needed for iron absorption and the metabolism of essential fatty acids by the mitochondria of the cell.  It has an integral role in adrenal function and the adrenal response to stress, as well as the production of sex hormones. Vitamin C has also been shown to promote ovulation.

As an antioxidant, vitamin C recycles other antioxidants such as vitamin E, protects cells from lipid peroxidation and protects DNA from oxidative damage that can result in mutations in genetic material.
During pregnancy vitamin C is important for the baby’s developing nervous system. Vitamin C also is important for regulating iron status in pregnant women. The levels of vitamin C in the body are decreased by stress, infections and smoking.

Alpha Lipoic Acid

Alpha Lipoic Acid (ALA) is present in every cell in the body for the conversion of glucose to generate energy. ALA is a unique antioxidant that is both water and fat soluble. ALA helps to regenerate other antioxidants such as vitamin C, E and glutathione. It repairs oxidized proteins and helps in the binding and excretion of toxic metal ions from cells.

ALA is present in most foods, particularly liver, kidney, heart, spinach, broccoli and yeast extract. However the amount of ALA in natural sources is very low. It is recommended to supplement 20-50mg/day of ALA during pregnancy to recycle vitamin C for foetal development. Most good quality preconception multivitamins contain around 50mg of Lipoic acid.

Vitamin D

Sufficient vitamin D levels are essential during pregnancy and especially during lactation when the newborn’s bones are developing.  Maternal vitamin D levels as well as calcium are required for foetal tooth development.

Deficiency of vitamin D during infancy can result in biochemical disturbances, reduced bone mineralization, slower growth, bone deformities and increased risk of bone fractures. Vitamin D is critical to both musculoskeletal and neurological growth and development of the infant.

Whether pregnant women require additional vitamin D supplementation has been investigated in some studies. Studies have demonstrated vitamin D supplementation lead to a greater newborn birth weight, and helped maintain higher levels of calcium and phosphate in both the mother and newborn. Women also experienced lower blood pressure.

Prenatal vitamin D levels may also have a preventative role for a range of autoimmune conditions.  There is great consensus regarding the need for vitamin D supplementation during lactation, with breast milk being recognized as a poor source of this vitamin. Infants are largely dependent on stored vitamin D acquired in utero.

Exposure to Ultra-violet radiation is the primary source of vitamin D for most people.  A recent study showed that  40.5% in women residing in southeast Queensland are deficient in vitamin D during winter and spring.  Healthy liver and kidney function is required for the conversion of Vitamin D to its active form.  It is imperative to test vitamin D prior to conception and if there is a deficiency take a supplement.

Coenzyme Q10 (CoQ10)

CoQ10 is an essential enzyme used by cells to generate energy. CoQ10 also works in the body as an antioxidant.  There is a correspondence between a low CoQ10 level and pregnancy complications, particularly in cases of spontaneous abortion before 12 weeks. There is also an association between low CoQ10 levels and fetal wasting in the first trimester. The highest concentration of CoQ10 in maternal plasma is found soon after delivery, with a peak in the third trimester of pregnancy. A high concentration of CoQ10 during the third trimester of pregnancy, may reflect a progressive increase in maternal requirements for foetal development, but also an increasing antioxidant protection mechanism for the mother during pregnancy and delivery. Recently a significant decrease in plasma CoQ10 has been reported in women with pre-eclampsia.

Probiotics

Lactobacillus acidophilus has a positive effect on estrogen excretion and can be beneficial for women with symptoms of estrogen dominance. Researchers found that eating these foods containing cultures of Lactobacillus acidophilus, such as yoghurt and fermented milk products, is associated with a lower incidence of breast cancer. This is attributed to reduced absorption of estrogen and other immune-enhancing effects of the lactobacillus bacteria.

The intestinal microflora differs in infants born by vaginal or caesarean delivery. The different intestinal microflora of a newborn will impact their immune system development. Infants delivered by caesarean section have fewer bifidobacteria at an early age and have a stronger predisposition for allergies.

Bifidobacteria are the most abundant members of the intestinal microflora during the first months of life, composing up to 60-90% of the intestinal microflora of a healthy breastfed infant. Early infancy is a critical phase in the development of the immune system and gut microflora has a long-term impact on the infant’s future health and the prevalence of allergies.^viii

OMEGA 3 DHA: Docosahexaeonic Acid

DHA is required for growth and development of the brain during the 3rd trimester and the early postnatal period.^ix 15% of brain growth occurs during infancy. The World Health Organisation recommends that pregnant women have at least 2.6g of Omega 3 Essential Fatty Acids containing 100-300mg of DHA to meet the needs of the developing foetus.^x Deficiencies in mothers results in poor visual acuity, poor neurological development and ill effects on behaviour.^xi One study of IQ on children aged 4 and their mother’s intake of Omega 3, found a positive correlation on cognitive development.^xii The Maternal diet needs to be adequate so that breastfed infants receive sufficient DHA. Formula fed infants only receive DHA when it is included in their formulas.^xiii

References

i	Tan PC. Review: calcium supplementation during pregnancy reduces the risk of pre-eclampsia. Evid Based Med 2008 Jun;13(3): 83. Abstracted from Hofmeyr GJ, Duley L, Atallah A. Dietary calcium supplementation for prevention of pre-eclampsia and related problems: a systematic review and commentary. BJOG 2007 Aug;114(8): 933-843. Epub 2007 Jun 12.
ii	Gishnan FK, Said HM, Wilson PC, Murrell JE (1986) Intestinal transport of Zinc and folic acid: A mutually inhibitory effect. Am J Clinical Nutr. 43, 253-262.
iii	Shalani S, Bansal MP; “Role of selenium in regulation of spermatogenesis: involvement of activator protein 1 Biofactors, 2005;23(3):151-62.
iv	Szymanski and Kazdepka-Zieminska A (2003) Effects of homocysteine concentration in follicular fluid on a degree of oocyte maturity.  Gineko Pol 74, 1392-1396.
v	O’Neill C (1998) Endogenous Folic acid is essential for the normal development of preimplantation embryos. Hum Reprod 13, 1312-1316.
vi	Szymanski and Kazdepka-Zieminska A (2003) Effects of homocysteine concentration in follicular fluid on a degree of oocyte maturity.  Gineko Pol 74, 1392-1396.
viii	Huurre A, Kalliomaki M, Rautava S, Rinne M, Salminen S, Isolauri E. Mode of delivery – effects on gut microbiota and humoral immunity. Neonatology 2008;93(4): 236-240. Epub 2007 Nov 16.
ix	Horrocks LA, Yeo YK., Health Benefits of docosahexaenoic acid (DHA): Pharmacol. Res. 40.3 (1999):211-25
x	[1] Banbrick HJ., Kjellstrom TE., Good for your Heart, but bad for your baby? Revised Guidelines for fish consumption in pregnancy. Med J Aust 181.2 (2004):61-2
xi	Helland JB et al. Maternal Supplementation with very long chain n-3 fatty acids during pregnancy and lactation augments childrens IQ at age 4. Pediatrics 111.1 (2003): e39-44
xii	Cohen JT et al. A Quantitative analysis of prenatal intake of n-3 polyunsaturated fatty acids and cognitive development. Am J Prev Med 29.4 (2005): 366 e1-e12
xiii	Williams C et al. Stereo acuity at age 3-5 years in children born full term is associated with prenatal & postnatal dietary factors: a report from a population based study. Am J Clin Nutr 73 (2001):316-22