The study published in The American Journal of Clinical Nutrition checked the amounts of choline and iodine in nonprescription and prescription prenatal vitamins. The research also checked for toxic metals like arsenic, lead and cadmium.

“During pregnancy, many women rely on prenatal vitamins and minerals to support their health and their baby’s development. Among the most crucial nutrients for fetal development are choline and iodine. However, some prenatal vitamins may not contain the exact amounts listed on the label and some may not contain any choline or iodine,” said the study’s first author Laura Borgelt, PharmD, MBA, professor at the University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences at CU Anschutz. “Our study aims to help women better understand the nutrient content in prenatal supplements, empowering them to make more informed choices and select the best options for their health and their baby’s well-being.”

The researchers tested a sample of 47 different prenatal vitamins (32 nonprescription and 15 prescription products) bought from online and local stores where people commonly shop. They then measured the actual amounts of choline and iodine in their lab versus what was on the label and also checked for arsenic, lead and cadmium. They compared their findings with official safety standards within 20% of the claimed amount.

The Food and Nutrition Board of the Institute of Medicine recommends dietary reference intakes for choline at 450 mg/day during pregnancy and 550 mg/day during lactation, with a tolerable upper limit of 3,500 mg/day. For iodine, the recommended dietary reference intake for females aged 19 and older is 150 mcg/day, increasing to 220 mcg/day during pregnancy and 290 mcg/day during lactation. The tolerable upper limit for iodine is 1,100 mcg/day.

Additionally, the United States Pharmacopeia has established purity standards for pharmaceuticals, including limits for harmful substances: arsenic (2.5 mcg per oral daily dose), cadmium (0.5 mcg per oral daily dose) and lead (0.5 mcg per oral daily dose).

The researchers found most prenatal vitamins do not list choline, and many of those that do, don’t contain the correct amount. Only 12 listed the choline content, which is about 26% and only five products (42%) had the right amount of choline as promised on the label.

When checking for iodine, they found most prenatal vitamins contain less than advertised, and very few provided the correct amount, with 53% of products listing iodine content, but only four (16%) products contained the claimed amount of iodine on the label.

They also found some products contained levels of heavy metals that were higher than expected. Specifically, seven products had too much arsenic, two had too much lead and 13 had too much cadmium, all above the purity limits set by the U.S. Pharmacopeia. Exposure to these heavy metals in pregnancy has been associated with adverse birth outcomes.

“We’re one of the first studies to measure the actual amounts of choline and iodine in a large sample of prenatal supplements. The presence of contaminants, especially cadmium, was also concerning. Our findings highlight a significant gap between what’s listed on the labels and what’s actually in the products, underscoring the urgent need for stronger regulatory oversight in this area,” Borgelt adds.

The authors mention that although there’s a need for more oversight in ensuring supplements have enough of each ingredient, prenatal supplements are still important to take during pregnancy. They recommend double-checking ingredients or working with a doctor or healthcare professional to choose the prenatal supplement.

This study was funded by the Center for Science in the Public Interest via a grant by the John Sperling Foundation.

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Traces of metal may enter the body through contaminated soil that infiltrates food, through drinking water, air pollutants or tobacco smoke. There is strong evidence that toxic metals, such as arsenic and cadmium, are cardiovascular risk factors. Arsenic and cadmium are often found in tobacco and food, while arsenic is also found in water. Titanium exposure is mainly derived from dental and orthopedic implants, screws, pacemaker encasings, cosmetic products and some foods.

“Metals are ubiquitous in the environment, and people are chronically exposed to low levels of metal,” said lead investigator of the study Maria Grau-Perez, M.Sc., of the Institute for Biomedical Research Hospital Clinic de Valencia INCLIVA in Valencia, Spain, and a Ph.D. candidate in the department of preventive medicine, public health and microbiology at the Universidad Autonoma de Madrid, in Spain. “According to the World Health Organization, 31% of the cardiovascular disease burden in the world could be avoided if we could eliminate environmental pollutants.”

Atherosclerosis develops when fatty deposits, or plaque, builds up in the arteries causing them to narrow, weaken and stiffen. Depending on the arteries affected, it can lead to a heart attack, stroke, angina, peripheral artery disease or kidney disease.

Prior research on the impact of metal exposure on atherosclerosis has traditionally centered on the carotid arteries, the major arteries in the neck. This study focused on subclinical atherosclerosis — before symptoms are present — and examined the impact of metal exposure on the carotid, femoral and coronary arteries. Previous research suggests that imaging of the femoral artery, which is the main artery supplying blood to the lower body, may lead to earlier detection of atherosclerosis.

Researchers evaluated 1,873 adults (97% men) in the Aragon Workers Health Study. The study participants worked at an auto assembly factory in Spain and ranged in age from 40 to 55. Researchers measured participants’ environmental exposure to nine toxic metals — arsenic, barium, uranium, cadmium, chromium, antimony, titanium, vanadium and tungsten — and the exposure’s association with the presence of subclinical atherosclerosis in the carotid, femoral and coronary artery regions. The study explored the potential role of individual metals and metal mixtures on the development of atherosclerosis.

During the participants’ annual occupational health visits between 2011 and 2014, socioeconomic and health information for each participant were recorded, including education level, smoking status and medication use. Each person in the study had a medical examination to measure body mass index, blood pressure, blood glucose levels, cholesterol levels, triglyceride levels and more. Urine samples were collected to assess metal exposure from air, water and food. Researchers performed carotid and femoral ultrasounds, as well as coronary calcium scoring tests.

The analysis found:

• Older study participants had higher levels of most of the metals measured in the urine
• The few female participants in the study had higher metal levels compared to men, when levels were measured in the urine.
• Adults who had smoked at any time showed higher levels of arsenic, cadmium, chromium and titanium than the people who had never smoked.
• Higher levels of arsenic, cadmium, titanium, and potentially antimony were associated with a higher probability of having subclinical atherosclerosis.
• Arsenic and cadmium appear to be most closely associated with increased plaque levels in the carotid arteries; cadmium and titanium are of greater concern for the femoral arteries; and titanium, and possibly cadmium and antimony, are of more concern for the coronary arteries.
• Arsenic may be more toxic for the arteries when found in combination with cadmium and titanium.

“This study supports that exposure to toxic metals in the environment, even at low-levels of exposure, is toxic for cardiovascular health,” said study co-author Maria Tellez-Plaza, M.D., Ph.D., a senior scientist at the National Center for Epidemiology and the Instituto de Salud Carlos III in Madrid, Spain. “The levels of metals in our study population were generally lower compared to other published studies. Metals, and in particular arsenic, cadmium, and titanium, likely are relevant risk factors for atherosclerosis, even at the lowest exposure levels and among middle-aged working individuals.”

The study included a very specific population of mostly men in one area of Spain, so the results may not be completely extrapolated to women or other populations world-wide. Additional research is needed to understand the mechanisms involved in the development of atherosclerosis based on associations to metals.

“Current global environmental, occupational and food safety standards for cadmium, arsenic and other metals may be insufficient to protect the population from metal-related adverse health effects,” said Tellez-Plaza. “Metal exposure prevention and mitigation has the potential to substantially improve the way we prevent and treat cardiovascular disease.”

Journal Reference:

1. Maria Grau-Perez, Maria J. Caballero-Mateos, Arce Domingo-Relloso, Ana Navas-Acien, Jose L. Gomez-Ariza, Tamara Garcia-Barrera, Montse Leon-Latre, Zoraida Soriano-Gil, Estibaliz Jarauta, Ana Cenarro, Belen Moreno-Franco, Martin Laclaustra, Fernando Civeira, Jose A. Casasnovas, Eliseo Guallar, Maria Tellez-Plaza. Toxic Metals and Subclinical Atherosclerosis in Carotid, Femoral, and Coronary Vascular Territories: The Aragon Workers Health Study. Arteriosclerosis, Thrombosis, and Vascular Biology, 2021; DOI: 1161/ATVBAHA.121.316358

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