Associations Between Multivitamin Supplement Use and Alcohol Consumption Before Pregnancy: Pregnancy Risk Assessment Monitoring System, 2004 to 2008

Surveys in the United States show a high prevalence of alcohol consumption among women of childbearing age that has been found to range from roughly 53% (Center for Disease Control, 2009) to approximately 60 to 70% (Caetano et al., 2006), with 12 to 14% reporting “binge” or heavy episodic drinking (Centers for Disease Control and Prevention [CDC], 2009; Naimi et al., 2003; Paintner et al., 2012). Alcohol consumption among this group of women is of public health concern since more than 50% of pregnancies are unplanned (Henshaw, 1998), and it is likely that a woman may unintentionally drink during the early stages of pregnancy (Paintner et al., 2012). It has been estimated that approximately 12 to 23% of pregnancies have some level of prenatal alcohol exposure (Center for Disease Control, 2009; Meschke et al., 2013). Maternal alcohol consumption, especially binge drinking, is the cause of the specific pattern of adverse birth outcomes known as fetal alcohol spectrum disorders (FASD). The range of adverse outcomes associated with prenatal alcohol exposure includes increased risks of structural malformations, pre- and postnatal growth deficiency, preterm delivery, stillbirth, spontaneous abortion, and cognitive and behavioral deficits (Feldman et al., 2012). FASD is estimated to affect approximately 1 in 100 births, rivaling autism spectrum disorders as one of the most common developmental disabilities (May and Gossage, 2001; Sampson et al., 1997). Although it is well-known that alcohol intake during pregnancy may lead to FASD, not every pregnant woman who consumes alcohol, even at high levels, will have a child affected with the disorder (Abel, 2001). A variety of factors are thought to modify the risk of FASD among women who consume alcohol. These include previous history of having an affected child (Li et al., 2001), older maternal age (Chiodo et al., 2010), and alcohol metabolizing genotype (Jacobson et al., 2006; Li et al., 2001; Warren and Li, 2005). There is ample animal data, and some human evidence to suggest that maternal nutrition may also play an important role (Paintner et al., 2012; Riley et al., 2011). Alcohol alters the metabolism of nutrients, resulting in reduced absorption and utilization, as well as increased absorption and can also interfere with the nutritional supply from the placenta to the developing fetus (Dreosti, 1993). In animal models, maternal diets that are nutritionally inadequate (especially in antioxidant nutrients, choline, iron, and folic acid) have been shown to exacerbate the detrimental effects of alcohol consumption on the fetus and demonstrate that nutrient supplementation may attenuate these alcohol-induced outcomes (Dreosti, 1993; Rufer et al., 2012; Thomas et al., 2009). Pregnancy increases nutritional requirements for several vitamins and minerals that are vital for the growing fetus (Pick et al., 2005). Due to the increasing demand for nutrients during pregnancy, many women do not meet the recommended intake through diet alone (Pick et al., 2005). Prenatal multivitamin supplementation use before and during pregnancy can improve maternal nutrition and help to meet the vitamin and mineral requirements which can more than double for many nutrients during pregnancy (Menard, 1997). The importance of periconceptual multivitamin supplement intake has been clearly demonstrated for the folic acid content of these supplements, which affords protection against neural tube defects and certain other congenital anomalies (Wilson et al., 2007). As embryonic development begins at conception, before most women are aware of their pregnancy, the benefits of multivitamin supplementation can best be obtained by supplementation that is initiated in the period prior to pregnancy (CDC, 2004; Wolff et al., 2009). However, surveys show that less than half of childbearing-aged women (Ammon Avalos et al., 2009; Kim et al., 2011; Sullivan et al., 2009) and less than one-third of women in the month prior to pregnancy (CDC, 2004; Yu et al., 1996) use multivitamin supplements. Although it is highly recommended that women of childbearing age who consume alcohol take a daily multivitamin supplement (Institute of Medicine, 1992; Menard, 1997), very little research has investigated multivitamin supplement use among alcohol consumers in the periconceptional period. Two studies have shown that multivitamin supplement use during early pregnancy may modify the risks of small-for-gestational-age, preterm birth (Avalos et al., 2011), and miscarriage (Ammon Avalos et al., 2009) associated with low-to-moderate alcohol intake; however, no studies to our knowledge have investigated dose–response associations between alcohol consumption and multivitamin supplement use before pregnancy. Therefore, we explored associations between periconceptional alcohol use (drinking and “binge” or heavy episodic drinking) and multivitamin supplementation use in participants from Pregnancy Risk Assessment and Monitoring System (PRAMS).