A Follow Up: Maternal Obesity from All Sides

Science & Sensibility readers may recall the Maternal Obesity from all Sides series* we did a few months ago.  Last week, while walking my dog and catching up on a few news podcasts, I heard this story on NPR’s Morning Edition—a segment that was a part of the news outlet’s series on Obesity in America.  The story discusses new research that looks at why it can be so difficult to lose and keep weight off from a hormonal and biological perspective.  The gist of the research referenced in this news piece is that when we concertedly work to lose weight, our body produces less of the hormone leptin (a natural appetite suppressant) which prompts a starvation signal in our brain, telling the body to conserve energy by decreasing metabolism and, at the same time, feel more hungry—prompting increased caloric intake.

Additionally, the Morning Edition segment made the point that once a person has gained more weight than that which is healthy for his/her stature, it becomes harder and harder to lose and keep the weight off.  As the reporter summarizes, “lower metabolism lasts a lifetime.”  (Despite this, some excellent points are later made in the segment which suggest that moderate exercise six days a week—such as brisk walking, swimming or cycling, can have positive effects on weight loss and maintenance.)

What does all this have to do with maternity care issues?

Well, in the Maternal Obesity from all Sides series, we discussed the growing correlations between maternal overweight and pregnancy and L&D outcomes:  how women of size are more likely to experience gestational hypertension and diabetes; how they are more likely to be offered labor inductions and undergo cesarean deliveries as a result of those comorbidities—whether or not those procedures are actually evidence-based for the given situation(s).  And we also discussed how addressing size and/or weight once a woman is pregnant is both unfruitful and unfair—because most of us recognize that pregnancy is not a time when a woman should be attempting to lose weight.  Likewise, it is not a time when a woman should be shamed for a preexisting condition (as if shaming is ever acceptable).

But, in the spirit of preventative care, I felt the NPR piece was enlightening: while there are MANY opportunities to improve maternal outcomes through preconception/interconception care, as pointed out in the recent blog post by Christine Morton, and the more distant series by Walker Karraa, perhaps working to prevent obesity in the first place—rather than focusing on after-the-fact individual or public health weight loss programming—is a better approach.  Because, according to the news segment linked to above, once extra weight has been acquired, losing and maintaining that weight loss is exceptionally more difficult.

A similar NPR story on All Things Considered aired just a few days earlier which covered this same topic and reviewed the findings of a study recently published in the New England Journal of Medicine.  The study by Priya Sumithran et al. assessed the hormone and metabolism changes that accompanied significant weight loss in severely calorie-restricted study subjects.  As described in the Morning Edition segment, Sumithran’s study described significant weight loss maintenance difficulties that were hormonally based.  In essence: maintaining weight loss is about hormones, not will power.

Women of childbearing age have enough maternity care-related challenges to face: escalating labor induction and cesarean delivery rates, racial disparities in access to care.  We talk a lot on this blog site about the cascade of interventions, a concept that is also frequently referred to in Lamaze teachings.  Perhaps it is time we should also be talking about a healthy cascade of prevention, with maternal obesity being a prime target.  Ideally this cascade of prevention begins well before women of childbearing age find themselves contemplating pregnancy, or preparing for birth.  But even as childbirth educators, we can play a part in this healthy cascade.  When covering postpartum topics, we can talk with our expectant parents about the importance of interconception health:  nutritious dietary choices and adequate exercise.  We can couch these discussions as approaches to optimizing health in various ways with various downstream benefits:  having adequate energy to play with one’s child(ren), reducing a family’s healthcare cost burden, and yes, laying the ground work for healthfully supporting a future pregnancy if and when that occurs.

As Dr. Miranda Waggoner stated in her interview with Dr. Morton, “…we do have to worry about viewing women as pregnancy vessels,” but I also think we need to begin looking at expectant women beyond just the here and now.

*The Maternal Obesity from All Sides series is also reviewed in the current Journal of Perinatal Education.  If you don’t already receive the JPE and would like to check it out, you can request a free copy of the journal here.


A Follow Up: Maternal Obesity from All Sides

November 8, 2011 07:00 AM by Dawn
Exercise CAN help a pregnant woman who is obese though with sugar and bp I think. I also wonder about fish oil or DHA. Nutrition is important even if a woman is obese. But yes, weight loss during pregnancy is not something to push, and making mom feel bad is not helpful.

A Follow Up: Maternal Obesity from All Sides

November 8, 2011 07:00 AM by Kimmelin Hull, PA, LCCE
Dawn, Thank you for your comments. And yes, exercise is important during pregnancy (uncommon, specific medical conditions aside, which may preclude the pregnant woman from exercise). In fact, ACOG has maintained for some time now that pregnant women should strive to exercise moderately most, if not all days of the week. And, as you aptly suggest, parameters like blood pressure and blood sugar levels can benefit from physical activity, even if the woman's weight continues to increase (as it should) during pregnancy. Our society tends to be so weight focused that we sometimes forget to consider other indications of health. *The Society for Canadian Gynecologists (SOCG) provides similar guidance for exercise during pregnancy which is more easily attained by non-SOCG members than the ACOG guidelines are, and also expounds upon postpartum exercise, including pelvic floor conditioning as well as making the point that moderate exercise is not harmful to the processes associated with lactation. Yeah SOCG!

A Follow Up: Maternal Obesity from All Sides

November 10, 2011 07:00 AM by The Well-Rounded Mama
Obesity is a complex topic. I wish there were more complexity in how we discuss it and more nuance in how we see it. I always appreciate when medical folks discuss it in a compassionate and nuanced way. However, I'd point out that while there are people who become "obese" over time through less-than-ideal choices, there are many people who don't "become" obese...they are that way their whole life, despite very normal habits and much effort not to be so. "Preventing" obesity through trying to help people from becoming obese in the first place may help some, but not all. It doesn't recognize that for some, it's not a matter of some behavior or outside force that causes fatness. One study that describes this is Loos and Bouchard 2003, www.pubmed.gov/14535962, which states that "the currently available evidence suggests four levels of genetic determination of obesity: genetic obesity, strong genetic predisposition, slight genetic predisposition, and genetically resistant." These predispositions will determine how responsive one's body is to obesity prevention efforts. When we discuss weight and health, it's important to recognize that not all obesity CAN be prevented at this point. Not all obesity is acquired. Of course genetics is not absolute destiny, but adoption and twin studies make it pretty clear that they are extremely influential for many, no matter what environment they are raised in. It's not ONLY about habits and outside influences. However, that doesn't mean a person of size cannot emphasize good habits. Nutritious eating and regular exercise is helpful across the board, regardless of size. It just doesn't always lead to weight loss. Nor do good habits always prevent every case of obesity either.

A Follow Up: Maternal Obesity from All Sides

November 10, 2011 07:00 AM by Kimmelin Hull, PA, LCCE
@The Well-Rounded Mama Thank you for your comments! I definitely agree that this is a complex topic and that genetics seem to be more and more related. That being said, I would also offer a couple additional thoughts: --> Rather than suggesting that a large percentage of obese people are that way their whole lives (ie. from the very beginning) perhaps it makes sense to suggest that while the majority of infants are born at normal weights (average birth weights in the U.S. are now ~ 7 1/2 pounds but have actually dropped in recent years*) the genetic predisposition to become obese has increased. Slight difference in language, I know...but "predisposition" does not = guaranteed outcome, right? --> According to some of the readings**/discussions in a public health course I'm currently taking, the incidence of obesity in our country has steadily climbed over the past ~ 100 years due to various factors such as: decreased labor jobs-->more sedentary jobs (thanks to technological advancements in numerous industries), decreased price of snack foods compared to the price of whole/healthy foods, and increase in prevalence of women (the traditional home-cooked-meals preparers) in the work force--yielding less time for cooking healthy meals at home and increasing reliance on less healthy, fast-food/microwaved meals. --> If the concepts behind epigenetics*** hold true (that genetic changes can occur over time/generations due to exposure to various environmental cues)then it would make sense that increasing rates of obesity (maternal, or otherwise) began as lifestyle/behavioral choices and gradually ingrained as genetic predisposition. Perhaps it would make sense, then, that this genetic predisposition could be reversed within a few generations with concerted (albeit difficult) efforts to increase activity levels...reduce poor quality food consumption..., etc. The hard sell of this, of course, would be convincing folks that their efforts might only show minimal results, personally, but that those efforts could have huge impact a couple generations down the line. I don't mean to offer a trite solution to a complex problem (thus, the 8-part series we did a while back that still only scratched the surface)but to simply suggest other vantage points that might help inform public health programming, along with a little bit of understanding of the issue of maternal obesity. * http://www.reuters.com/article/2010/02/18/us-birth-weight-idUSTRE61H6D520100218 ** Phillipson T (2001) THE WORLD-WIDE GROWTH IN OBESITY: AN ECONOMIC RESEARCH AGENDA Health Economics 10 (p1-7). ***http://www.sciencedaily.com/releases/2009/04/090401181447.htm

A Follow Up: Maternal Obesity from All Sides

November 11, 2011 07:00 AM by The Well-Rounded Mama
Of course it's not ALL genetics; there are many factors involved, and environment and genetics do interact. There are societal factors (more sedentary lives overall, more easy access to food, especially refined carbs etc.) that do impact things as well. But genetic factors are stronger than people think, as adoption studies indicate, and we do a disservice to many people of size if we attribute the development of obesity only to "bad behavior" or think of it exclusively as an acquired trait. Epigenetics is an interesting concept but one we are only beginning to understand, so it's important to be careful. However, I do wonder about the influence of some of the draconian weight gain restrictions from the 40s, 50s, and 60s on obesity rates today. We know from the Dutch famine (and other famines) that babies of women who experienced very restricted intake during pregnancy and then had normalized intake later in life had higher rates of obesity, diabetes, yadda yadda. The women of a generation or two ago did not have that level of starvation, but some of the restrictions were still pretty stringent (not to mention the promotion of smoking to limit weight gain). I wonder how much of societal weight increases recently was influenced by that, as well as by environmental factors? Another reason why the trend to keep "obese" women from gaining any weight in pregnancy is worrisome to me. Anyhow, I think there are many factors influencing weight in our society, and the story is a complex one. However, there is an awful lot of emphasis in the typical medical dialogue about obesity that focuses on blame, that emphasizes obesity as an acquired trait, a result of "bad habits" or "obesogenic" environment that is relatively fixable if you just avoid junk food, eat whole foods, and get more exercise. This ignores the experience of so many people of size that do all these things and still are fat, or still have fat kids, despite doing all the "right" things. It's a fine line to recognize that environmental factors do matter and we should promote fixing those things as much as possible, but also not to assume that fixing those things will automatically solve most of the obesity "problem" or prevent childhood obesity. There's an awful lot of blame implied in a lot of these discussions, and that's incredibly frustrating to people of size who do work at healthy habits but don't see it translated into results at the scale for themselves or their children.

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