October 8, 2018

     What are some special micronutrients to pay attention to during the first 1000 days before birth? Over the next few sections, we will explore the research and recommendations for some critical micronutrients.

Number one on my list is Vitamin D. It is super important as the master switch for bone health and the immune system's police called T regulator cells. Vitamin D is arguably the most important micronutrient for human health. It is one of the four fat soluble vitamins and has the added benefit of

being naturally synthesized by our skin via exposure to the sun's UVB rays.

In order to set the stage for vitamin D and pregnancy, we need to take a step back to the root issues surrounding vitamin D in general life. We all love sunny days and the effect the sun has on our psyche and feelings of wellness. For centuries humans have lived by the sun whether by regulating our sleep cycle or producing our natural foods. Yet, recently we have shunned the sun's direct effects on our bodies by avoiding it through excessive indoor activity and overusing sun-blocking agents and lotions. Skin cancer rates have increased steadily since the 60's and 70's ushering in a period of sun phobia. True to our nature, we chose the extremist way of dealing with the problem, total avoidance.

This campaign, prodded along by the Dermatology community, has helped produce a generation of Vitamin D deficient Americans. In the recent past the medical community believed that Vitamin D simply controlled calcium and phosphorus metabolism and bone health. Evidence now shows this to be the tip of the iceberg. Vitamin D stimulates the immune system from birth and plays a critical role in natural immune system function. Inadequate levels of Vitamin D are being linked to autoimmune disease and cancers. (Aranow et. al. 2011) Vitamin D is also known to be involved in the function of many nuclear genes and many aspects of cell differentiation. (Haussler et. al. 2010)

There are many diseases that are noted to be more common at northern latitudes on the globe where sun exposure is limited by indoor behavior because of temperature and the sun's height in the sky. (Leary et. al. 2017)(Masterjohn 2011) After much review, the link appears to be in large part due to Vitamin D deficiency and limited UVB sun exposure. Our lifestyles have increased sedentary indoor work and recreation thereby reducing sun exposure year round now. Couple this with the knowledge that sunscreens also effectively reduce the suns beneficial effects and you start to see the picture. According to the National Institutes of Health and other studies there is an inverse relationship between Vitamin D levels in the body and autoimmune disease and cancer. (Garland et. al. 2006)(Aranow et. al. 2011) It is time for pregnant women and frankly everyone to pay attention to this ever important hormone made in our skin.

What does that data say about pregnancy and vitamin D? The pregnancy specific issues related to insufficient and deficient vitamin D status turn out to be all related to dysfunctional births. There is an increased risk of preeclampsia, premature birth and babies being underweight at birth which in turn are detrimental to the newborn's development. (Wei et. al. 2013)(Aghajafari et. al. 2013) Having a premature birth has a host of consequences for the baby depending on the severity of prematurity and the difficulty of the birth.

 There is also some emerging data that low maternal vitamin D levels are associated with maternal hyperglycemia, gestational diabetes. (Lu et. al. 2016) (Poel et. al. 2012) Maternal hyperglycemia causes elevations in fetal insulin levels which acts as a growth hormone for the baby. This can cause birth complications in select newborns. 

Going back to general health and the reason behind the recommendations to avoid the sun, skin cancer. The goal of prevention of skin cancer should be to avoid sunburns which are a noted risk factor for cancer. Exposure to 15 to 30 minutes of direct sun a day without sunscreen has never been shown in any way to be dangerous, however, the beneficial effects on Vitamin D levels are well known during this brief exposure at peak day sun. (Nair et. al. 2012)

The esteemed and also embattled Dr. Holick, a dermatologist and Vitamin D specialist from Boston University, has espoused prudent sun exposure and the evaluation of your Vitamin D status, especially, if one suffers from bone pain, muscle weakness, chronic fibromyalgias, osteoporosis, irritable bowel syndrome and other non specific inflammatory diseases. (Garland et. al. 2006)

Aside from sun exposure, where can we get vitamin D? Food and supplements. Food sources of Vitamin D are dairy, fish, eggs, mushrooms and fortified foods like orange juice and cereals. A diet that includes oily fish like roughly 3 ounces of salmon will provide 400IU of Vitamin D. Weight bearing exercise is also a part of a healthy lifestyle plan and recommended for pregnant women. The axial loading of body weight on the skeleton has a beneficial effect on the prevention of bone loss and also improves mental wellness both of which are great for mom and baby.

Some other caveats are to remember that your skin color dictates how fast you can make D. Darker skin = more time to generate adequate D and lighter skin is the converse. Between the months of November and April, it is quite difficult for most individuals to generate adequate D from the sun in the mid to northern United States. Dark skin color is an advantage for preventing skin cancer, but a disadvantage for developing vitamin D. (Garland et. al. 2006)

From a supplement perspective, most pregnant women need 2000-4000 IU/day if they are indoors excessively and are not getting enough sun exposure daily. (Hollis et. al. 2011) The actual dose must be based on your Obstetrician's recommendations.

Max dosing of supplemental vitamin D for all adults appears to be 4000 IU per day before toxicity can develop although this is never recommended while pregnant unless blood levels are closely monitored. Over consumption of vitamin D can be toxic as it is fat soluble and can accumulate in our fat cells. Symptoms and findings of toxicity include hypercalcemia, bone pain, kidney stones, calcium deposits in the body. Diseases that could increase the risk of toxicity include: sarcoidosis, hyperparathyroidism, tuberculosis, lymphoma and other cancers. There is only one way to be sure that you are not in the toxic range and that is to test 25 OH vitamin D blood levels. I highly recommend this test if you are taking 4000IU or more daily and are pregnant.

Pregnant women that are at increased risk for insufficiency or deficiency have: sun avoidance behavior, issues with intestinal fat malabsorption (vitamin D is a fat soluble vitamin like D/E/K), intestinal dysbiosis, inflammatory bowel disease, eating disorders, celiac disease and disorders of bile production or pancreatic enzyme production, chronic kidney disease, magnesium deficiency and older age.

Get some sun daily,

Dr. M

British Medical Journal Aghajafari Article
Journal of Investigative Medicine Aranow Article
Journal of the American Osteopathic Association Leary Article
Christopher MasterJohn Article
American Journal of Public Health Garland Article
Journal of Steroid Biochemistry and Molecular Biology Haussler Article
Journal of Bone and Mineral Research Hollis Article
Archives of Gynecology and Obstetrics Lu Article
Journal of Pharmacology and Pharmacotherapeutics Nair Article
European Journal of Internal Medicine Poel Article
Journal of Maternal Neonatal and Fetal Medicine Wei Article