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Maternal Obesity from All Sides

[Editor’s note:  in this  installment of our maternal obesity series, Dr. Kathleen Kendall-Tackett will guide us through a review of maternal obesity as it pertains to breastfeeding.  To read this series from the beginning, go here.  Tomorrow, we will finish up with some final thoughts from Well Rounded Mama’s, Pamela Vireday, on prevention strategies.]

I remember the moment quite clearly. I was at a large, international breastfeeding conference and stopped to read the research posters. As I did, I grew more and more irritated. There were several posters describing special interventions for “obese women.” Some of these interventions involved sending “obese women” to breastfeeding classes designed to address their “special” needs. Excuse me? First of all, the design of these studies appeared to assume that “obese women” are a homogeneous group, which they obviously are not. Second, why a class? Does the fact that they are heavy mean that they need special instructions? I’m certain that these colleagues meant well, but we have to ask whether this approach is a good idea.

OK, I’ll admit it: I’m a radical on this issue. My stand is due, in part, to the treatment that fat people—and fat women, in particular—receive in health care settings. The story goes something like this. Fat girl goes in for a medical exam because she’s been having concerning symptoms. Health care provider attributes all her health care problems to her size and sends her away with admonitions to lose weight. Only later, does it turn out that she has something awful, like cancer—a condition her HCPs missed completely because they made assumptions based on her physical appearance. Think I exaggerate? This scenario recently happened to the daughter-in-law of one of my friends.

Yes, but what about diabetes, heart disease, and the increased risk of complications following surgery, you might ask? Fortunately, I actually study diabetes, metabolic syndrome and heart disease. Obviously, health care providers do need to address any increased risk their patients might experience. So if their patients have high blood pressure, triglycerides, or LDL cholesterol, by all means address that. But we need to address those concerns without making sweeping assumptions about women who happen to have a higher BMI. For example, one colleague told me that she tells her obese patients that they need to lay off the soda and potato chips. The question I asked was whether she knew–for sure–that her fat patients were drinking soda and eating potato chips. Or that her slim patients weren’t? Did she know this or was she making assumptions based on prejudice against fat people?

Most of the proposed policy changes designed to address the “obesity epidemic” are, in my opinion, good ideas—for everyone, not just fat people. Get fast food and soda machines out of the schools? Great idea. Encourage more physical activity? Also good. Encourage increased consumption of whole grains, fruits and vegetables instead of highly refined and calorically dense junk food? Fabulous.

These approaches to obesity are all good. But we need to recognize a couple of things. First, even with all these interventions, some people are still going to be bigger than others. That isn’t necessarily a health problem. Second, someone can fall into the “obese” range on the BMI and still have good, sometimes even better cardiovascular health than someone who is smaller. Is size really an indicator of overall health, or is it perhaps simply one marker of many? Further, when someone brings up the issue of obesity to me, one of the first questions I ask in response is “how obese?” That makes a difference in terms of what type of problems we are likely to encounter. Assuming that all women who cross the “obesity” threshold have more health problems is simply wrong. Sometimes they do, sometimes they don’t. Third, providers sometimes assume that obesity is simply due to eating too much; that it’s just a matter of getting these women to take their faces out of the feeding trough. We’ve learned relatively recently, however, that it’s not quite that simple. In the past five years, there have been numerous studies demonstrating the role of depression, psychological trauma (particularly childhood abuse), and sleep disorders in weight gain and obesity. Yes, depression (and trauma and sleep problems) can make you fat. And there is also the matter of genetics. Some people are genetically programmed to be larger than others. Steps that these patients take to improve their health will improve their health. But these interventions may not significantly change their size.

So back to the question of a special breastfeeding gulag for fat girls. These interventions assume that women over a certain BMI will automatically have breastfeeding problems. When I’ve raised this issue with my colleagues, I’ve heard arguments about how larger breasts can cause problems, or that fat women have lower prolactin levels after birth.  They also assure me that fat women feel more shame about their bodies and will be reluctant to breastfeed when outside their homes, something we know is related to earlier breastfeeding cessation. OK, these things might possibly be problems. But women overcome breastfeeding problems all the time. The question we need to ask is whether we are creating self-fulfilling prophecies about these women. Breastfeeding is largely a confidence game. If we communicate to women that they think they will fail, whether we say this directly, or indirectly by sending them to a special class¸ are we setting them up for failure? This is a lesson we had to learn about mothers with issues such as flat nipples. Yes, these women can have more problems, but they don’t always. When we make flat nipples an issue, and communicate that mothers will likely fail, we can increase the rate of breastfeeding failure.

As for the shame issue, keep in mind that while there are discernable physical markers of obesity (such as BMI), obesity is also a social construct. Not everyone who is fat feels badly about it. In fact, in some ethnic minority populations, fat women are considered attractive. (And from an evolutionary standpoint, carrying some extra poundage is actually a survival advantage.) The question we need to ask is whether obese women with positive body images are having more breastfeeding problems than their smaller peers. I strongly suspect that they are not.

Frankly, it’s time for empowered fat girls to speak out on behalf of our sisters who do not yet know that they have a voice.  Women of size deserve respectful care, not shaming.  Is packing these women off to a breastfeeding fat camp a good idea?  Personally, I don’t think so. And I can’t imagine how you would market these classes to mothers. How many would willingly sign up for classes designated for obese women? (“Oh yes, that’s me. Please sign me up!”) While we want to proactively address any problems we think that these women may encounter, we need to plan our interventions with circumspection and care. Women of all sizes deserve no less.

Posted by:  Kathleen Kendall-Tackett, who is a health psychologist and board-certified lactation consultant. She is a clinical associate professor of pediatrics at the Texas Tech University School of Medicine in Amarillo, Texas. The views expressed in this posting likely do not reflect the official views of the Texas Tech

Maternal Obesity, Uncategorized , , , , ,

  1. June 14th, 2011 at 09:15 | #1

    All these thing you mentioned are absolutly true. My mom has always been large (11.4 at birth!) and when I was only 135lb she ate LESS than I did, had more energy (I still can’t keep up with her and she’s in her 60s) and still couldn’t loose weight. There are many different factors.

    One study found that 75% of people lost weight on a low-cal diet. The Report concluded that weight lose was simply a matter of cals-in-cals-out. But I want to know about that 25% who DIDN’T lose weight on the low-cal diet. Obviously my mom is in this group though she desperatly wants to loose.

    Another presupposition is that large women have large breasts. This isn’t so much medical as fasion, generally. I now weigh 200lb when not preggo, yet don’t fill an A cup. Most large lady clothes have enough room to carry the baby in the top along with all I got! It’s a little frustrating to go clothes shopping to say the least.

    So even if I, an obese woman, took the breast feeding for lorge women class, little or none of it would apply to me.

    We just can’t catagorize people. we are all unique.

  2. June 14th, 2011 at 13:46 | #2

    So refreshing to hear someone besides me saying these things! Thank you, thank you Dr. Kendall-Tackett!

    Another thing rarely taken into account in bfing rates in women of size is the influence of birth interventions….i.e., a very high rate of inductions, IV fluids, cesareans……which can interfere with breastfeeding initiation.

    And hardly anybody mentions PCOS, polycystic ovarian syndrome, which can impact breast development in teens and then affect their milk supply later. Lisa Marasco has done some groundbreaking work on this, but hardly anyone has followed it up, and it’s only rarely mentioned in research reviews of the topic. We need to be addressing this much more!

    I have a post on my blog about this:

    http://wellroundedmama.blogspot.com/2010/08/breastfeeding-in-women-of-size.html

  3. June 14th, 2011 at 19:25 | #3

    Thank you for the candor and attention to advocating for the well being of all women and children. I particularly appreciate your underscoring mental wellness. Your story reminded me of being 8 months pregnant in the waiting room of UCLA Neuropsychiatric Institute and feeling the “crazy mommy alert” all around, while I waited to see my physician.

    I would like to offer that the same inclusive, nonjudgmental paradigm be endorsed throughout the birth community to women who carry the burden of mood disorders in pregnancy, birth, and postpartum. The stigma there is SO great, as you know, that it doesn’t even get to the discussion, class, childbirth education stage. It goes unspoken, untreated, and under represented in the birth community.

    And not unlike issues of obesity, the poorest women in the wealthiest country suffer the most from both untreated perinatal and postpartum mood disorders, and obesity.

  4. June 15th, 2011 at 07:57 | #4

    Wonderful essay and very true. Teaching with laughter is the BEST!

    At the same time, obesity is recognized as a global epidemic. All the more reason every woman that is able to breastfeed, does; all the more reason that everybody help in this relatively easy and cheap public health strategy.

    Please remember too, that it sometimes takes more work from hospital staff to take care of an obese person. Example: it took 8 of us young nurses to give a bath and change the sheets for our intensive care patient with Chronic Obstructive Pulmonary Disease (COPD) who weighed 550 pounds. We have to find creative ways to support hospital staff too, and encourage them to find the Light in each person.

    warmly,
    A former ICU nurse.

  5. avatar
    Jaimie
    June 15th, 2011 at 14:19 | #5

    I remember before getting pregnant etc. i went to my old OB who i hadn’t seen in a while. We sat in his office and he read aloud as he wrote his notes. “Patient is morbidly obese” (i’m NOT morbid btw) Then he looked at me and said “why don’t you just walk 30 minutes a day? that will take care of it.” And when i asked him to use a smaller speculum he said “i can’t, you’re so big the walls will just cave in and I won’t be able to see anything.” – when I went to see a new OB – I told him what the other doctor had said. He was UTTERLY shocked at the callous behavior – and when i said the walking part, he looked at his belly and back at me and said “I walk plenty, it hasn’t helped me.” He and the ob he referred me to when I got pregnant (he retired from OB) were both fabulous. Nothing was mentioned about my weight except in a pragmatic “test for GD a little earlier” type way. Yes I was induced, and it went wrong, but it was b/c I had GD that i was induced, not b/c I was heavy. A lot of the nurses and LC’s suggested Football hold for me when nursing, again, not because of my weight but because of the size of my chest. :) With this 2nd daughter i’m at 1 year of successful nursing now. Dealing with weight pragmatically, and not in a demeaning way is absolutely critical. Thank you for this wonderful essay.

  6. June 15th, 2011 at 14:51 | #6

    Speaking as an enormous breasted woman (34 H) who has always been heavy and before this pregnancy was teetering on the line between heavy and obese. IMHO those of us who are heavier have LESS body issues. It seems I’m constantly reading stories about thin women who eat nothing but roasted skinless chicken, broiled salmon no sauce, brown rice and veggies. They always say things like, “I’m too vain to eat food with more taste.” Would I like to be skinnier – yeah. But I’m comfortable enough w/ my body that I eat cheese and cook w/ butter etc…
    Large breasts are an issue. Chief among them is finding a good fitting nursing bra and a good fitter. So unless the LCs and OBs and everyone else want to hire or learn how to fit bras the classes aren’t going to help much.

  7. June 17th, 2011 at 13:41 | #7

    Thank you thank you thank you. These are the things I’ve been saying for years. My bmi is 37 and I know when I feel healthy and when I don’t. I also eat healthier than most. I was also abused as a child and often wonder if my body holds onto the weight for emotional reasons.

    Blessings to your work.

  8. avatar
    Diana
    October 17th, 2011 at 21:53 | #8

    I am a big girl and have successfully breastfed all my babies for a minimum of 1 year. I have not had a single problem nursing in public. If my baby is hungry, I whip it out. I am proud of my breasts, I am amazed at what they can do. Even though the size they get while breastfeeding at times is a little uncomfortable, nothing like a 38J. My boobies work just fine despite my size.

  9. avatar
    Shannon
    October 17th, 2011 at 22:14 | #9

    Thank you for this! I had been breastfeeding for 5 years and tandem breastfeeding for 3 before I found out it was supposed to especially hard for me due to my size. I was between 275 and 295 while I was having babies (non-pregnant weight). Due to my build, that’s not as bad as it would be for some other women… I had a specialist tell me that if I was under 220 any pregnancy-related problems I had would not likely be due to my weight because of my build, and I suspect she was right. I had some difficulty learning to nurse my first, but none of it was weight related. I breastfed for 14 years. Generally speaking, I prefer to know if my weight could be an issue for me before I get into anything, but in hindsight, it was good I didn’t know it could be an issue for breastfeeding… that information might have been all it took for me throw in the towel when it was really hard.

  10. avatar
    Nicole L.
    October 17th, 2011 at 22:34 | #10

    As an obese woman who is also a breastfeeding momma, I have to admit that I had no idea that larger women would have any additional struggles with nursing that a typical size momma would! I suppose from a size perspective I’d say my issues have been that I’ve always needed a boppy pillow to comfortably feed my boys. I was nervous about nursing in public with my first, and would all but smother him with a blanket in an effort to stay covered. The third time around has been the easiest…I wear a tank top under my t-shirt so that when I lift my shirt, no skin is exposed (I think that draws more attention than anything, and no one wants to see my stomach, lol), and then I am able feed my kiddos while comfortable.

    Perhaps at the age of 38 I just have a different mentality on life than I did when I was younger. My size does not dictate the person I am, nor does it make any bit of difference in my ability to breastfeed!

  11. avatar
    Melissa
    October 17th, 2011 at 22:41 | #11

    Thank you for this series. I practiced as a Licensed Midwife in Washington for 5 years and served women of a wide range of sizes. I was shocked & saddened by some of the advice my clients heard from other providers (young, thin first time mom being told she’d gained by WIC “enough” weight at 28 weeks, heavy mom asked if she was sure she wasn’t due next week, etc).

    I was still completely unprepared for the bias I received in my own care.17 months later, I’m still offended & hurt by the overheard conversation between my midwife & the OB in the OR talking about how I needed special adhesive over my sutures because of my high BMI. My midwife has added high BMI to the list of risk factors she won’t accept for her practice.

    Not research based, not productive. Thank you again for standing up for facts about fat.

  12. avatar
    Megan
    October 17th, 2011 at 22:50 | #12

    Other then learning to position a newborn, which ummm even skinny women have to do; ive had wonderful breastfeeding experiences w all 3 of my children. I have ranged from a 40F to a 56K. Can u imagine, yup my back hurt! I even tandum nursed for 2yrs. I nursed in public frequently. I still nurse my 2yr @church during services. Its all abt education &support. I nursed my first 2kids for 3.5yrs :-)…i wouldnt change a thing. Im sure my youngest will nurse atleast as long. As they get older its more private. In many ways my size helps me be more descrete. LLL is great!

  13. avatar
    Lucia, CLC
    October 18th, 2011 at 01:19 | #13

    As a morbidly obese woman, and mother of 4 breastfed babies I can’t agree with you more. I even have the added risk of having PCOS and I still breastfed twins with no problem. A class is NOT the answer and discrimination only hurts women. YES we have additional risk factors. PCOS, and Thyroid can cause supply issues. Obese women are more likely to have pre-eclampsia and need mag sulfate with will delay lactogenesis 2. We are statistically more likely to need a c-section and thus are more likely to hemorrhage and suffer pituitary insult or Sheehan’s syndrome. These are of course all medical risks that should be assessed and early and frequent monitoring of the mother and baby in the early weeks and months is important. If a mother is obese or even morbidly obese, had not trouble getting pregnant, has a low risk pregnancy and birth and postpartum, there is no reason to think she’s at any greater risk for breastfeeding difficulty then any thin woman. Labeling her because she’s fat is just an insult.

  14. avatar
    Elizabeth
    October 18th, 2011 at 08:31 | #14

    I am not a large woman, but I do have pretty sizeable breasts and I do think that I had a few issues with breastfeeding that were specific to my shape. For example… every single bit of literature I got told me how I HAD to get my entire areola in my baby’s mouth. Um. No. And I didn’t even find out about the football hold until day 2 or 3 (previously I had been doing a normal old cradle hold and thinking I was going to suffocate my baby or I would have to nurse hunchbacked). Just some caveats – like a footnote even – to “regular” breastfeeding lit or suggestions need to be made… it would have made my life a smidge easier.

  15. avatar
    Anna
    October 18th, 2011 at 08:33 | #15

    I would have been mortified and mystified had I been sent to classes for fat-mums. I’m not sure what they would have to talk about in ‘special’ classes. No doubt they would do more harm than good, putting doubt into mothers’ minds and giving incorrect information (as per the article, sweeping genralisations don’t apply to everyone).

    I am classified as ‘obese’ and am much heavier than I should be – my weight is always underestimated as I carry it all over, rather than any one spot like most people. My whole family is like this, I stopped wishing to be thin the day I looked at pictures of my hungry, hard working Scottish ancestors with their thick legs and stocky build. If they couldn’t be thin then I don’t have a chance in hell of it, my aim is to be healthy and the right weight for my build. I’ll get there one day!

    I was fine during my pregnancy, no GD, but got gestational hypertension towards the end of it. Giving birth was completely trouble free but I did struggle to establish my milk supply and to latch my daughter on at first. 6 weeks in and we were both pros. I have fed her in every position you could imagine.

    It never dawned on me to be ‘ashamed’ of my body when breastfeeding in public, I’ve always fed my daughter whilst out and about without any thought about what people might think about my body. They are too busy looking at the cute baby to give me a sideways glance!

  16. avatar
    Heidi
    October 18th, 2011 at 08:55 | #16

    Nikki Lee :Wonderful essay and very true. Teaching with laughter is the BEST!
    At the same time, obesity is recognized as a global epidemic. All the more reason every woman that is able to breastfeed, does; all the more reason that everybody help in this relatively easy and cheap public health strategy.
    Please remember too, that it sometimes takes more work from hospital staff to take care of an obese person. Example: it took 8 of us young nurses to give a bath and change the sheets for our intensive care patient with Chronic Obstructive Pulmonary Disease (COPD) who weighed 550 pounds. We have to find creative ways to support hospital staff too, and encourage them to find the Light in each person.
    warmly,A former ICU nurse.

    Nikki Lee- I can only imagine how frustrating that must have been! My sister is a BSRN and has similar stories to tell. HOWEVER I ask you to consider the fact that many health care professionals look at the charts, see the numbers and when they go to see the patient- see what they expect to see. I was in hospital recently, and had surgery. According to every chart- a 5 foot 9 inch tall 265 lb woman is morbidly obese. Yet- I was inexplicably able to lift myself up onto the operating table, and was- within 6 hours of surgery- able to roll myself over in bed, sit up, and take myself to the toilet. There is a HUGE difference between me and the person you cared for- yet we both are considered morbidly obese. I can lift my washing machine. I can carry both of my sons- whose weight totals over 80 lbs. I am healthy. I am hard to fit for weelchairs, bras, and hospital gowns. Lifting me- unconcious would take as much effort as lifting a 5 foot 4 inch tall woman weighing the same amount. But I am most definitely NOt morbidly obese, except on these blasted charts. I delivered both of my babies drug free- and nursed them both for over 18 months. I am large. I am fatter than I’d like, I have huge breasts and flat nipples and I was stunningly successful compared to most other skinny mommas. The facts are that weight needs to be taken into account only after all other factors for a disease or injury have been accoutned for.

    Blessing,
    Heidi

  17. avatar
    aim
    October 18th, 2011 at 08:58 | #17

    I am actually glad to hear they had a class for larger moms. It was frustrating for me to attend La Leche meetings where all these skinny women could easily hide themselves under a small baby blanket and nurse so nicely while I felt uncomfortable with my body and embarrassed to feed my baby in front of them. I would have liked to share ideas and stories with women in my same situation. Also, I have an under active thyroid and was unable to nurse two of my four children. I suspect that some obese women have the same thyroid issues and I would like to know how it affected their nursing efforts.

  18. avatar
    Jessica
    October 18th, 2011 at 17:05 | #18

    I am obese and breastfed my daughter until she was 18 months and am exclusively breastfeeding my 3 month old boy who, by the way, is in the 98th percentile for weight! All on my va-va-voom twin set.

  19. avatar
    Athena
    October 18th, 2011 at 18:06 | #19

    This interests me. I would be curious to see a study which correlates obesity, education, income and breast feeding. The link between low income and less educated women (or, people in general) and obesity is clearly established. I believe I’ve read that there is also a link between low breast feeding rates in low income and less educated women. It isn’t all that strange to me to think that breast feeding rates may be lower in obese women NOT just because they are obese, but because of the other mitigating factors which impact successful breast feeding rates (lack of education or support, or the fact that many low income people have higher odds of having to return quickly after birth to a job which perhaps lacks the support or resources for a pumping Mom). I would be curious to see the success rates of Mothers who are obese, but educated and not low income, vs. those who are low income or uneducated and obese. I don’t know that I am explaining myself well, but I hope that you understand what I am getting at.

  20. October 18th, 2011 at 21:01 | #20

    Athena,

    You are actually making perfect sense. There is a theory which pertains to health behavior information dissemination that goes all the way back to 1970, called the Knowledge Gap Hypothesis (Tichenor, Donohue and Olien). In short, the hypothesis explains that a disparity exists in consumption of health-related information and that, in general, folks with higher socioeconomic status (higher levels of education, wealth & locale) tend to receive, absorb & implement health information more effectively than folks in lower socioeconomic (LES) groups. There is even a history of research that delineates how knowledgeable people are, based on through which avenues they receive their news (newspapers ==> more knowledgeable; television ==> less knowledgeable) (Viswanath, Finnegan, 1996).

    Because no trend is 100% representative of the entire population, I imagine there are plenty folks who fall within LES parameters who are also very well informed, very knowledgeable about heath issues and are generally very healthy, but if we are to look at this from a trend perspective then, yes, there does seem to be some strong correlation between SES, breastfeeding success and even birth outcomes for that matter.

    As you aptly point out, there are likely MANY mitigating factors that influence this complex issue–requiring an equally complex set of solutions.

  21. October 18th, 2011 at 21:06 | #21

    Good for you Jessica! Keep up the great work…

  22. October 19th, 2011 at 09:40 | #22

    @Kimmelin Hull
    …And this just out from the American Academy of Pediatrics re: breastfeeding support by low income fathers:
    http://www.aap.org/pressroom/fathers.pdf

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