The Institute of Medicine recommends that "overweight" women gain 15-25 lbs. in pregnancy, while "obese" women should gain "at least 15."
[Please note that last little bit.....at LEAST 15, not "only" 15. Many studies and doctors classify obese women as "gaining too much" if they gain more than 15 lbs., when in fact the IOM guidelines do not set an upper limit on weight gain in obese women.]
However, as we have discussed recently, there is a strong movement among some doctors to pressure the IOM to lower the guidelines for acceptable weight gains in women of all sizes, but particularly in obese women. They want the IOM to recommend that obese women gain little or no weight in pregnancy, which (once you consider the weight of the baby, placenta, and various fluids) basically amounts to encouraging obese women to lose weight in pregnancy.
But in REAL life, what are fat women being told about weight gain? Are they being given the 15 lb. limit, more "generous" limits, or are they being told to not gain any weight?
I have been working with women of size for many years now, analyzing the research, reading and collecting the birth stories of women of size, as well as birthing my own children as a "morbidly obese" woman. I have read/heard the birth stories of many, many women of size. What I have found is that, on average, most obese women are told to gain up to 15 or so pounds in pregnancy, sometimes 15-25 lbs if they have a more liberal healthcare provider. They are usually strongly discouraged from gaining more than that.
Sometimes you can find providers who simply emphasize good nutrition and reasonable intake and are accepting of whatever weight gain accompanies that. But most often, it seems that fat women are given the "around 15 lbs." advice, consistent with the IOM guidelines.
On the other hand, there are certainly many stories of fat women being told not to gain weight at all, being put on diets, even being told to LOSE FORTY POUNDS WHILE PREGNANT (yes, that's a real story).
Here are some quotes from fat women about their weight gain advice, in their own words, collected over the years. These are only the ones that I saved; there are many more (like the "lose 40 lbs." edict) that I didn't save, but which I remember clearly. Entries have been edited slightly for punctuation etc. and for clarity.
Women who were told to gain only up to about 15 lbs. in pregnancy:
- The OB doc that told me I was to only gain 10 lbs through my whole 9 months; this after losing 30 in my 1st trimester.
- My original ob tried to tell me that I only needed to gain 10 lbs for my whole pregnancy.
- Although my OB is a decent man, he constantly hammers me about my weight (I've lost 3 lbs. during this pregnancy so far), and I am scared to death to step on the scales at my appointments.
Women who were told to gain very little weight in pregnancy:
- At the first appoinment the doctor I saw was very concerned that I had planned a pregnancy at my weight...He sent me to a dietician and told me that I was only supposed to gain 3 lbs.
- My doctor keeps telling me I cannot gain any weight during my pregnancy. She said if I do it will cause more harm to my baby.
- [After I found out I was pregnant,] my doctor then proceeded to ruin the moment by telling me that at 210 pounds I was not going to be allowed to gain any weight in pregnancy if I wanted a healthy baby.
- I had my first OB appointment yesterday, and I came out rather discouraged! I weigh 265 lbs, and my doctor told me ideally he doesn't want me to gain ANY weight with this pregnancy. I can't win! I even have to "diet" when I am pregnant.
- My first OB told me..."Oh my God, you're dreadfully overweight - you shouldn't gain anymore than seven pounds."
- The OB, during my pelvic exam while she had the speculum in and was scraping the Pap smear, said in a hostile tone of voice, "You realize that you are quite obese and this puts you at high risk for many serious complications. So I don't want you gaining any weight during this pregnancy." And then in a very condescending tone of voice, "So no eating for two." [Follow-up: When this woman complained about the doctor's rudeness, especially during a vulnerable pelvic exam, the doctor "fired" her from her practice because she "failed to follow medical advice."]
These women were encouraged to go to a diet program/diet while pregnant:
- [The nurse-midwives at the birth center] sent me to Weight Watchers and told me not to gain weight or they wouldn't be able to keep me.
- Before getting pregnant this time, I was on Weight Watchers...and had lost 25 lbs. When I found out I was pregnant, I quit Weight Watchers. But after meeting with the OB nurse this week, she said that I could go back to WW.
- [The doctor] said I mustn't gain more than 20 lbs., 15 was even better, because I was overweight to begin with. If I gained more, he'd put me on a diet...I left the doctor when I was 5 months pregnant. [My] cousin stayed, and obeyed. When she reached her weight limit he [did] put her on a diet.
- I was told not to gain any more weight when I reached about 7 ½months with my first 2 pregnancies (w/OBs). So I’d try to starve (and not succeed) during the 8th & 9th month when my little guys were trying to grow their brains!!
- I was told to stop gaining weight or I would "be a fat woman for the rest of my life." These were his exact words before he told me to eat nothing but lean protein [and vegetables.]
- I just got back from [a non-pregnancy doctor], and had him (again) tell me that I am grossly overweight and need to lose weight even though I am 7 months pregnant.
- I am 9 weeks pregnant and [my midwife] said I need to go on a diet. She said I can go back to Jenny Craig, like I was doing before I was pregnant.
- I have gained 18 pounds so far..[the doctor] had a fit. She told me that I would not be "allowed" to labor if I was carrying another 9 pound baby, and I had better lose weight. I asked, "Do you mean not gain any more?" and she said, "NO, I said you need to LOSE weight. Walk for 30-60 mins a day, and quit eating carbs." I have never heard of a OB telling a woman going into her 3rd trimester to lose weight - is an 18 pound [gain] SO BAD???
Some women were subjected to dire predictions of what would happen if they gained "too much" weight:
- I went to a CNM who delivered at a hospital. I started my pregnancy at 163 pounds on my almost 5'8" frame. I eat a vegetarian diet, and have for many years...When I was about three months along, I went to see her for my second prenatal, and weighed in at . She then told me that I should start eating less and just make sure I took my vitamins everyday or else I would get "too fat to be able to deliver vaginally." Absolute direct quote; I will never in my life forget those words, or how bad that made me feel.
- I weighed around 180 pounds when I got pregnant. I didn't make any effort to keep my weight down, but only gained about fifteen pounds for some reason....a few days before my delivery the doctor reviewing my records complimented [me] on controlling my weight, and said it was a good thing I hadn't gained five more pounds because otherwise, I "could have died!" I guess she thought you just hit the 200 mark and keel over! (Since then I had another baby. I weighed 220 pounds when she was born. I had a midwife assisted homebirth with no complications.)
So the advice to fat women on gaining weight while pregnant is fairly variable, from "lose weight" to "just eat healthy and don't worry about the gain." Most commonly, the advice seems to align with the IOM guidelines of about 15 lbs. for "obese" women. [Whether that's a good thing or not, of course, is still up for debate.]
But as you can see, dietary and weight gain advice often comes with a lot of moralizing, a lot of judgment, and even hate talk. This is unacceptable. I would challenge doctors and midwives out there to find a way to talk to their clients about nutrition and weight gain concerns without condescension, without moralizing, and without judgment. Women of size deserve respectful treatment at all times, even if you think that their habits need "fixing" or "changing." Alas, respectful treatment is sorely lacking for many women of size in pregnancy.
And it's important to note that there ARE women being told to gain NO weight in pregnancy (which is essentially to lose weight) and some who are being advised to LOSE weight outright (even including the baby etc.), despite questions about the safety of such an approach. Even Dr. Artal's own study showed an increase in underweight babies in some fat groups that did not gain weight. These babies present their own health concerns, both immediately postpartum and in the long run. The safety of such an approach is far from established.
One of the most objectionable things to me about the "bariatric obstetrics" approach is the constant media pressure that Dr. Artal and others are putting out there, trying to create public pressure on fat women to not gain weight in pregnancy. Even if he doesn't succeed in pressuring the IOM to change its weight gain guidelines, the constant media spin creates a climate of fear around eating and weight gain for women of size, and constant expectations from doctors and family members that gaining any weight while pregnant at a larger size is dangerous and eating in pregnancy must be strictly curtailed.
Because of the media spin on this, more and more fat women will live in terror of eating during pregnancy, and more and more fat women will follow restrictive and rigid practices, instead of common-sense, healthy eating regimens. As Sandy at Junkfood Science notes, it is indeed "Science by Press Release."
It's time for "Science by Press Release" to stop, time for a more careful look at the research, and time for some common-sense approaches to weight gain in pregnant women of size.
Coming soon: More posts about weight gain in pregnancy, including the reality of what fat women typically gain (as opposed to what they're told to gain), why the fuss about weight gain at all, possible problems of hypocaloric diets in pregnancy, and reviews of some of the studies about weight gain in fat women. Stay tuned!