The True Facts About Your Prenatal Supplements with Dr. Behzad & Hannah Varamini of Tend Prenatal
I get a lot of questions about supplements, and I could not be more excited to have the founders of Tend Prenatal joining me today to share a ton of great information with all of you about supplements and prenatal vitamins.
You can order Tend Prenatal at their website. They have graciously offered us 20% off an order by using the code EGGWHISPERER (all caps).
Dr. Behzad and Hannah Varamini are a married couple who started Tend Prenatal, which offer prenatal supplements with a twist. Hannah is an artist and start up consultant with a lifelong aversion to pills. Behzad has a PhD in Human Nutrition with an emphasis on prenatal nutrition and infant brain development. After their own fertility journey that included two pregnancy losses, they have created a business that nurtures women in all stages of fertility, pregnancy, and postpartum.
Dr. Aimee: What made you decide to start your own company?
Hannah: We never dreamed we’d actually start a business together!
But when we started trying for a baby, we realized a couple things: firstly, I really couldn’t stomach any of the prenatals out there. Behzad started furiously reading all the prenatal supplement labels and didn’t approve any of them. It was this perfect collision of my problem with Behzad’s expertise.
Dr. Behzad: I’m reading all these labels and I find myself disappointed — all my training in nutrition pointed towards one conclusion: real foods, not synthetic vitamins, lead to optimum health outcomes, both in pregnancy and for overall health. My dissertation was actually focused on prenatal diet and infant brain development. So I spent three years, most of it in the pandemic, sourcing ingredients, testing recipes, and having tasting parties, to arrive where we are today with Tend, the world’s first real food prenatal (in the form of a delicious, snackable bar).
Dr. Aimee: How did you arrive at the decision to focus on a non-pill approach?
Hannah: I’ve struggled to swallow pills since I was a kid. I remember my mom made me swallow these huge vitamins and I just couldn’t do it, and got really upset, it was mildly traumatizing.. Even as an adult, I despise pills. And prenatal pills are among the largest, and sometimes most horrible smelling pills out there.
I wasn’t alone — some studies estimate 40% of people have trouble swallowing pills too.
As we studied everything out there,we found that all prenatal pills were made with synthetic ingredients and synthetic nutrients, and the powders and gummies aren’t any different
Dr. Behzad : The non-pill approach gave us the opportunity to play around and do things that no prenatal has ever done.
First, we sought out all our nutrients from foods, since so much of my research, and we’ll discuss this later, demonstrated that foods provide superior nutrients to synthetic vitamins in every way. Our ingredient list is literally spinach, kale, broccoli, sweet potatoes, sunflower seeds, etc. 100% plant-based, real foods providing all our nutrients.
Second, Tend includes nutrients not normally found in prenatals like calcium and magnesium, since, in some cases, so much of these particular nutrients are required that they can’t possibly fit into a pill.
Third, we were able to provide macronutrients (protein, fiber, fat) alongside the micronutrients, since requirements for macros increase during pregnancy as well.
Finally, the non-pill approach allowed us to focus on making the product tasty and enjoyable. As I saw Hannah struggle with pills, my main goal was to remove that struggle and replace it with a moment of delight.
We spend a lot of time formulating and taste testing. It’s really important that Tend tastes like something you’d want to look forward to. That’s why we decided to launch with our three core flavors Peanut Butter Chocolate, Lemon Berry, and Chocolate Sea salt, and also make fun seasonal flavors.
Dr. Aimee: How did your own fertility journey play into your decision to create Tend Prenatal?
Hannah: We’ve had two pregnancy losses. The first time we got pregnant relatively quickly. We made it to around 8–9 weeks and even saw the heartbeat before we lost the pregnancy. Around a year later, we got pregnant again. We did some genetic testing and found out there was a genetic abnormality but we were hopeful. However the pregnancy ended in another miscarriage around 16 weeks. It was really devastating.
My experience made me realize how so many women suffer silently — since around 1 in 4 women experience miscarriage. Getting pregnant and staying pregnant is often a difficult, rollercoaster process. If something goes wrong, you wonder, “is it my fault?” There’s a lot of self-blame and guilt. We want to remove that burden of “have to do” — I have to take my prenatals even if they make me feel queasy — there’s already so many “have to dos”.
The whole pregnancy journey is hard enough. We want to bring joy to the process, bringing something tasty (not to mention actually better for you too). It’s interesting the launch of Tend coincided with our personal story. After years of taking those horrible prenatals, we launched Tend and got pregnant a third time — and just had our rainbow baby girl in May!
Dr. Behzad: The years of infertility gave us time to sort of examine everything. And in those years, I became obsessed with how to provide the most optimum, safest nutrients Hannah needed in a form she would enjoy taking. Knowing that we were making something that Hannah would put into her body every day as we tried to have a baby, especially given our two losses, the stakes for me were very high, especially when it came to safety of ingredients. Building what I thought was the best prenatal became my biggest goal.
Dr. Aimee: Let’s talk a little bit about supplements. What nutrients do women who are trying to conceive, or who are pregnant need?
Hannah: Many women may have heard about folate which is vitamin B9, or its synthetic form, folic acid. This nutrient is critical in preventing neural tube defects, and it’s in every prenatal supplement and even fortified many food products in the US.
Then there’s choline, which more than 90% of women in the US are deficient in. Like folate, choline is critical for the development of a baby’s brain and nervous system. Taking choline has been shown to increase blood supply to the placenta (that’s a good thing), as well as improve processing speed and attention span of young infants. Sidenote: the synthetic form of choline, choline bitartrate has actually been shown to be potentially harmful, and we’ll revisit this in a bit.
Dr. Behzad: Iron is also important during pregnancy, as the body’s requirement increases significantly to support the increased blood supply needed for growing the baby (and anemia in pregnancy is still a sizable problem in the United States). For maximum absorption it’s important to take iron with Vitamin C.
Vitamin D: It’s hard, even in California, to rely on sun exposure alone for sufficient Vitamin D, and most prenatals simply don’t have enough Vitamin D. Studies have shown that levels of vitamin D much higher than those found in most prenatals are safe, tolerable, and can reduce the risk of preeclampsia, gestational diabetes, preterm birth, and low birth weight in humans.
Magnesium: more than half of women of child-bearing age in the US are magnesium deficient, and most prenatals do not include magnesium. In human trials, prenatal magnesium has been shown to reduce growth restriction and increase birth weight.
The list goes on, but that’s a good sample of the most important prenatal nutrients and, quite often, some that women are most deficient in.
Dr. Aimee: You mentioned moments ago an important distinction about prenatal choline. Can you expand on that?
Dr. Behzad: Of course. A 2021 randomized clinical trial, the gold-standard of human research, showed that the most popular form of synthetic choline, choline bitartrate (as found in most prenatals), posed dangerous risks compared to choline found in foods.
In this study, synthetic choline bitartrate was found to increase levels of TMAO. TMAO is a metabolite, or a chemical, in the blood, that’s elevated in gestational diabetes and preeclampsia, and it’s also been shown TMAO is an independent risk factor for adverse cardiac events in dozens of studies. So, TMAO is bad, and synthetic choline bitartrate raises levels of it. In the same study, choline from foods, phosphatidylcholine, like from sunflower seeds or eggs, did not raise TMAO.
In addition to raising TMAO, synthetic choline bitartrate also made the subjects’ platelets more sticky. Stickier than normal platelets increase the risk for blood clots and can decrease blood flow to critical organs, which of course in pregnancy, blood flow to the placenta is critical. So, again, synthetic choline bitartrate caused platelet stickiness, as opposed to the choline form found in foods which did not adversely affect platelets.
The take home here is this: these synthetic nutrient forms aren’t always safe, and supplement companies don’t have to prove that they’re safe before selling them — synthetic nutrients often have different structures than nutrients found in foods and, as it turns out, structure matters.
Hannah: We wish more people knew about this clinical trial and the dangers of synthetic choline bitartrate. We wish other prenatal companies would swap this ingredient out for natural choline, which is of course more expensive and harder to source. But this is an issue we don’t find many people in the space talking about, and no supplement companies have changed course.
We even see prenatal companies listing their choline bitartrate as “food form choline”, which is misinformed and misleading.
Dr. Behzad: And, just to be clear, Tend’s choline is sourced from sunflower seeds.
Dr. Aimee: Many people reach for a prenatal vitamin. Is that sufficient, or are there other things fertility patients should consider?
Dr. Behzad: We want to highlight a 2019 study published in the Journal of the American Medical Association — Obstetrics and Gynecology. This study looked at more than 1,000 pregnant US women and closely studied their diets and prenatal supplements — the first comprehensive study of this kind.
Here is the conclusion of their study, straight from the paper:
“[Our] study suggests that a significant number of pregnant women are not meeting recommendations for some essential nutrients-vitamins D, C, A, K, and E, as well as iron, folic acid, calcium, potassium, magnesium, and choline-even with the use of dietary supplements.”
So of the 1000 women taking prenatal vitamins, most were still deficient in 12 or more nutrients. So, deficiencies across the board while STILL taking prenatal vitamins … clearly, something isn’t working.
Hannah: Part of the problem is that prenatal vitamins are simply missing nutrients. Or, that the synthetic forms of nutrients are not as well absorbed by the body.
So even if you’re taking a prenatal vitamin, you have to make sure it has the right nutrients in the right forms that your body can recognize and actually use.
Dr. Behzad: Getting a quality prenatal vitamin is important. But, philosophically, and scientifically, we think the evidence all points towards a food-first approach, which means getting nutrient dense foods in the meals and snacks you eat throughout the day.
Dr. Aimee: Scientifically, how are foods a better way to get nutrients?
Dr. Behzad: There are a few things that make getting nutrients from foods superior to popping pills, powders, and gummies.
One, is simply the evidence. In a landmark editorial published by the American College of Physicians, a group of medical doctors and PhDs from several schools, Johns Hopkins Medical School included, stated the following:
“Enough Is Enough: Stop Wasting Money on Vitamin and Mineral Supplements”
Actually, that was just the title!
This paper reviewed and summarized dozens of studies looking at the effects of synthetic multivitamins and mineral supplements on health outcomes: heart disease, cancer, longevity, etc. And the conclusion was this:
“We believe that the case is closed- supplementing the diet of well-nourished adults with (most) mineral or vitamin supplements has no clear benefit and might even be harmful.”
Essentially, summarizing the hundreds of studies examining the benefits of synthetic supplements, the authors again conclude, and I quote, “No substantial health benefit.”
Now of course, there are some benefits to synthetic supplements for some very specific stages of life, like folic acid for preventing neural tube defects in early pregnancy. But a preponderance of evidence says, “no benefit”.
To address your question head on,”How are foods better,” synthetic supplements will also break your heart if you look at them in side-by-side studies against foods. In an important and well-designed study from Tufts University, the intake of vitamins A and K, magnesium, and zinc were carefully measured. Scientists discovered that when these nutrients were obtained from the diet, subjects were less likely to die of heart attacks and other diseases but when these nutrients were obtained from synthetic supplements? There was no health benefit.
If you consider nutrition from an evolutionary perspective, this entirely makes sense. We’ve been eating foods and extracting the nutrients from them for hundreds of thousands of years. We have enzymes and receptors and transporters that are specifically tailor-made to bind to and transport and store the nutrient forms that are found in foods.
However, synthetic lab-made vitamins and minerals often have different chemical structures than those found naturally in foods, usually to help make the synthetic vitamins more “shelf-stable” … These differences in structure result in diminished absorption of synthetic nutrients compared to those in foods (example: And, no surprise, vitamin E from foods is absorbed twice as well as Synthetic Vitamin E, due to structural differences)
Also, synthetic vitamins don’t come delivered alongside the same other chemicals or co-factors found in foods. In foods, vitamins and minerals exist alongside co-factors that are co-delivered alongside vitamins, which increase vitamins’ potency.
Because of this sort of cooperation among nutrients and chemicals in foods, naturally occurring Vitamin C when found in foods is a 300x more powerful of an antioxidant than synthetic vitamin C: we call it food synergy — nutrients in foods working together to enhance each other’s biological effect and potency, and even to enhance each other’s absorption (like vitamin D and Calcium). So, in addition to structure, synergy is one important way foods are superior.
Given this research, it was critical for us to build a new type of prenatal sourced completely from foods.
Hannah: We just talked about it with choline, there’s also the issue of safety. Some synthetic nutrients have not been previously studied and we don’t know their side effects. While it’s easy to overdose with synthetic vitamins, no one is reporting adverse reactions to too many fruits and vegetables, and it’s almost impossible to overdose on vitamins and minerals from foods.
Dr. Aimee: One of the questions I get very regularly from patients is about egg quality, and if it can be improved. What foods and/or nutrients have studies shown can help improve egg quality?
Dr. Behzad: Let’s begin with a caveat. As many listeners likely know, egg quality is affected by a variety of factors, most notably a woman’s age. Fertility, as listeners likely know, is very complex and at times, mysterious. So I can’t suggest or promise that a specific diet or nutrient will guarantee egg quality or bring about fertility. All I can do is tell you what the studies say. And I find the data from a few studies to be quite promising.
First: omega-3 fatty acids. An important study from Harvard and Massachusetts General Hospital showed that egg quality was improved by dietary omega-3 fats, and that egg quality was reduced by dietary omega-6 fats. Omega-3 sources of fat include fish oil, or algae oil, and also important but less potent, flaxseed oil and oil from nuts and seeds. Omega-6, which we already over consume, is most commonly found in soybean oil, corn oil, safflower oil — these foods aren’t necessarily bad, they’re just over consumed, again reducing egg quality.
The study’s conclusion reads like this: “the intake of a diet rich in omega-3 fatty acids and limited in the omega-6 fatty acid content may delay the natural decline in oocyte quality that occurs with age, thus potentially allowing for continued successful reproduction and decreased aneuploidy rates.”
Reference: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5624332/
Similarly, In a paper titled, “omega-3 fatty acids and treatment outcomes among women undergoing assisted reproduction” also from Harvard, serum levels of long-chain ω3-PUFA were positively associated with probability of live birth among women undergoing ART.
For every 1% increase in serum (or blood) omega3, the probability of clinical pregnancy and live birth increased by 8%.
Reference: https://pubmed.ncbi.nlm.nih.gov/29136189/
Secondly, antioxidants play a critical role in maintaining ovarian function and have been shown to moderately improve egg quality. This is because all cells, especially as we age, are prone to increased oxidative stress, which is an imbalance between the number of oxidative free radicals produced (can damage cells) and the body’s ability to fight those oxidative compounds.
The best place to get antioxidants is from foods. And one antioxidant in particular, N-acetyl-Cysteine (NAC) was shown to preserve egg quality in several studies, stabilizing egg DNA and protecting the cell’s mitochondria, which is part of the cell that creates energy. Good food sources of NAC include beans, spinach, salmon, and tuna.
Reference: https://pubmed.ncbi.nlm.nih.gov/25482371/
Third, and this may sound a little surprising, melatonin treatment has also been shown to decrease oxidative stress and suppress the natural age-related loss in number and quality of eggs, and in one small study in 2008, melatonin co-administered with vitamin E led to increased fertilization rates in IVF patients.
Reference: https://pubmed.ncbi.nlm.nih.gov/18339123/
Hannah: Finally, and of course, everyone talks about CoQ10. The data are mixed on effectiveness, but what is clear is that the CoQ10 levels in oocytes, or eggs, decrease as women age. This is why CoQ10 is such a popular supplement for women trying to get pregnant.
Reference: https://pubmed.ncbi.nlm.nih.gov/26111777/
Dr. Behzad: There are also dietary factors that can hinder fertility, so here are some things you want to avoid:
Number one: Trans fat and “unhealthy diets” (processed meats, potatoes, sweets, and sweetened beverages”) were found to have negative effects on fertility rates and egg quality.
Secondly: Red meat is linked to poorer embryo quality in a study of couples going through IVF treatment.
Reference: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6079277/
In addition: Women who consumed high amounts of fast food and few fruits/veggies generally took longer to become pregnant than those with healthier diets.
Reference: https://pubmed.ncbi.nlm.nih.gov/29733398/
It’s not only dietary factors, but about a dozen studies showing pesticide exposure can cause complications for fertility, disrupt egg release and decrease egg quality.
Again, the reasons we outlined here are dietary, but women struggling with fertility will be best served going to a qualified healthcare practitioner, namely an experienced and board certified OBGYN, alongside positive changes in their diet. There are many challenges related to fertility that require much more than dietary changes and necessitate the help of a doctor.
Join Dr. Aimee for The IVF Class Dr. Aimee: In your research, have you found data that suggests that diet or nutrition can improve the likelihood of implantation?
Dr. Behzad: In humans, the data is more limited here as compared to egg quality, as factors affecting implantation are complicated and often difficult to study.
Critical to implantation are endometrial artery blood flow and microvessel density.
Most of the promising research that I’ve found here is from animal studies and I can think of one in particular worth sharing.
So dietary protein, or amino Acids, are important here. Specifically, one particular amino acid, arginine, was shown to be beneficial in an animal study at improving occurrence of implantation — the mechanism it does this is by acting as a precursor to a chemical called nitric oxide. Nitric Oxide functions to open up, or dilate blood vessels, thereby increasing blood flow to tissues, including the uterus.
Dr. Aimee: Since your expertise is in omega-3, can you give 3 things we don’t know about omega 3 throughout pregnancy? Dr. Behzad:
- Omega-3 fats have strong anti-inflammatory effects. A little known fact: in the body, they are converted to a family of molecules that slow down inflammation.
- Not all omega-3s are created equal. “Long-chain” omega-3 fats, such as those found in fish and algae, have different biological effects, and are more important from a dietary perspective, than purely plant-based omega-3 fats more commonly found in nuts and seeds. It’s the long-chain fats that are concentrated in our brains preferentially over the type found in things like flax and almonds.
- DHA in the prenatal stage has been associated with a greater than 50% reduction in early preterm birth and healthier birth weight. Further, studies show that DHA also supports postpartum mental health.
Because of studies like these, Tend provides DHA at ACOG recommended levels.
Dr. Aimee: Given that many people are relying on prenatals to get their vitamins, what nutrients do you feel women are missing in pregnancy?
Hannah: Here are four nutrients women are missing in pregnancy, often even while taking a prenatal.
- Choline: 90% of women are deficient
- Iron: 84% are deficient from diet, nearly 40% are still deficient while on prenatals
- Vitamin D: 90% of women are deficient from diet, most prenatals simply do not contain enough
- Magnesium: 50% of women are deficient with prenatals
Dr. Aimee: And in addition to Tend, how do you recommend they meet those needs?
Dr. Behzad: We emphasize eating a healthy, colorful, well balanced diet. Think of the phrase “eat the rainbow” at every meal. Those different colors in various fruits and vegetables are in large part caused by different vitamins and nutrients found in each plant.
Hannah: We also recognize that physical and mental/emotional health are intertwined. So other things like community, exercise, support, friendships -obviously there’s so much more than only nutrition. The season of trying to conceive can be difficult and isolating. We’ve learned along our journey that seeking out support with people walking by your side is super important. We have so much to be thankful for, especially the community that surrounded us both during the pregnancy losses, in the launch of our business, and now as a family of three.
Resources mentioned in this episode:
Article: Serum omega-3 fatty acids and treatment outcomes among women undergoing assisted reproduction
Originally published at https://draimee.org.
