Monday, July 21, 2008

Obesity and Weight Gain in Pregnancy, part 3

What Do Fat Pregnant Women Actually Gain in Real Life?

As we have seen in this series, there is a move afoot to lower the pregnancy weight gain guidelines from the Institute of Medicine (IOM). We've discussed the people behind this push, and we've discussed what advice fat pregnant women are actually receiving about weight gain.

Now the question is, how much weight do most fat women actually gain in pregnancy? Do most follow the "only gain 15 lbs." rule? Do most gain more? Less? It's one thing to have guidelines on paper, it's another thing to see what happens in real life.

Many doctors and research articles contend that fat women gain "excessively" in pregnancy. The way this is phrased in the media spin makes it sound like fat women are stuffing down everything in sight because being pregnant gives them an excuse to "eat for two," and that they are all out of control, gaining huge amounts of weight.

Yet if you look at the research studies, they consistently find that fat women gain LESS weight than average-sized women. But because the IOM threshold for fat women is 15 lbs., what is a "normal" gain for every other woman (25-30 lbs. or so) is automatically categorized as "excessive" for fat women.

So when you read that research shows overweight and obese women are "gaining too much weight," remember that this is because they are being held to a different, stricter standard.

Is this a fair and realistic standard?

If you look at the graphic above, even if fat women gain NO weight for fat/protein stores, and gain the least amount of weight in each of the other categories, the minimum weight gain is 17 lbs. And yet fat women are regularly told to only gain 15 lbs., or almost none if you go by the new standards some doctors are pushing. How is this a realistic standard?

Furthermore, much of the prenatal weight gain research is tainted by inadvertent errors. The fact is that many fat women actually lose weight in the first trimester or so of pregnancy. However, pregnancy weight gain is often calculated from the first prenatal appointment, so any first-trimester loss is often not accounted for in official records. So researchers may be overestimating pregnancy weight gains in women of size, unless they figure gain from your pre-pregnancy weight.

The point is that these "excessive" gains being recorded in fat women are often because researchers are holding fat women to a stricter standard than average-sized women, and because they often figure gains from the first prenatal weight, rather than from pre-pregnancy weight. So the reports tend to get distorted.

But that leads us back to the question.....what do fat women REALLY gain in pregnancy, in REAL life? What's a realistic standard?

Highly Variable Gains

When you look closely, what you find is that there is a LOT of variability in the weight gains of fat pregnant women. Many fat women gain about 15-25 lbs., while others gain <15 color="#000000">All of these may be variations of NORMAL. The truth is that fat women's weight gains are all over the map. Even when mothers' nutrition is excellent and they are getting regular exercise, a wide range of weight gain is not unusual.

This is reflected in my own data. Over the years, I have collected the birth stories of several hundred women of size, from women who are just barely plus-sized to women who weigh over 400 lbs. You can find these stories at my website,, in the "BBW Birth Stories" part of the site.

As a way to help categorize the stories, I asked each contributor to enter data about her pre-pregnancy weight and weight gain in pregnancy. This gives me a database of information about pregnancy in women of size to pull from. Because it's taken from stories women submit, it's not a truly scientific database, but it still can offer some insight into the way that women of size gain.

My data upholds the idea that weight gain in pregnant women of size is highly variable.

  • The largest group of gains is the 0-15 lbs. group, with most of these women falling in the top 2/3 of that range (5-15 lbs.)
  • Then comes the 15-25 lbs. group, with the group equally spread within this range
  • Close behind is the 26-35 lbs. group, with most of the gains in the bottom to middle (around 26-30 lbs.)

Although the results are not equal between these three groups, they do tend to be fairly well distributed. The vast majority of large women will fall into the first two groups, with a slightly smaller (but still significant) group in the third category. In other words, most fat women gain somewhere between 5-30 lbs. during pregnancy.

Doctors who want to lower the weight gain standards for women of size claim that lower gains will help lower the risk for cesareans in this group. However, the data from my site doesn't support this idea. The majority of women who had cesareans actually had gains in the 0-15 lbs. range. An increase in excessive weight gain was not the cause of the cesareans in this group. More often, cesareans there seem to be due to fetal malpositions or failed inductions.

Weight Gain Patterns Along the Fringes

But what about the fat women who had a cumulative weight loss or a high weight gain during pregnancy? Although these were outside the usual gains of most women of size, they're not all that unusual. But if you read the stories of these women more closely, you begin to notice some patterns.

Those who had a cumulative weight loss during pregnancy often tended to be those who started at very large sizes, or those who experienced problems like severe nausea in pregnancy or hyperemesis. Most do not recount being put on hypocaloric diets, but note that the weight loss happened "without trying" or in spite of their efforts to gain weight. Although the reason for this is unclear, it may be that in some women, pregnancy improves their metabolism so strongly that a net loss occurs.

Those who had high weight gains in pregnancy often were those who experienced pre-eclampsia (where fluid retention tends to make weight gain larger than normal), those who were chronic yo-yo dieters, those who had eating disorders (bulimia or binge eating disorders), or those who had lost a great deal of weight just before pregnancy.

For example, one woman has 7 birth stories on my site (she has since had more babies). She is courageously frank about having a strong history of bulimia and starting her first pregnancy at a lower-than-usual weight. Once she stopped purging, she gained 110 lbs. in that pregnancy. In later pregnancies, after her weight had stabilized at a higher weight, she gained anywhere from 0 to 30 lbs. each time. In one pregnancy where she had a terrible case of hyperemesis, she lost a total of 23 pounds. In another pregnancy where she had deliberately lost 115 lbs before the pregnancy, she gained 60 lbs.

So in one woman, pregnancy weight gain varied from a loss of 22 pounds to a gain of 110 pounds.....quite a wide variation, but perhaps not unexpected in someone with such a tumultuous weight history. (However, we should hasten to add that even when she gained 110 lbs., she still had a vaginal birth, something some doctors would lead you to believe is impossible. Such a variety of weight gains is not ideal, yet in the end her outcomes were okay.)

In the extremes of documented gains on my website, the lowest "gain" was a loss of 54 pounds, and the highest gain was the one listed above, +110 lbs. So while the majority of gains fell in the 0-15 or 15-25 lb. category (and this is probably the most realistic ideal), there really was quite a variety of weight gains documented.

This is echoed in the 2003 research in the "International Journal of Obesity," which compared weight gain in Finnish women between groups in the 50s/60s, in the 80s, and in 2000-2001. They found:

Overweight women gained the least weight in all the three cohorts. These findings are similar to the results from earlier studies....Obese women gained the least. On the other hand, variation in pregnancy weight gain has been the largest among overweight and obese women.

So large women tend to gain LESS than average-sized women, but their gains are highly variable and may range from very large gains to quite large losses.

Still, MOST fat women tend to gain in the middle, either in the 0-15 lbs. range or the 15-25 lbs. range. Some doctors will see this as justification for lowering the IOM guidelines, but again, that's just not very realistic. Although many women gained in the 0-15 lbs. range, most in this category gained in the 5-15 lb. side of the range. Very few women gained <5>

Although some fat women do gain little/no weight (or even lose weight), is this a realistic goal for most fat women? Is it even a healthy one? How possible is it really to manipulate weight gain anyhow? And what might the fallout be of restricting the pregnancy gain of someone who would otherwise gain normally? Do we even know? Aren't we playing with dynamite to try to manipulate things like this?

Generalizations About Weight Gain Patterns in Women of Size

There are some typical weight gain patterns in women of size. They don't hold true for EVERY fat woman, but there are some general trends you can pick out.

In general, the larger you start, the less weight you tend to gain. Women who tend to have larger gains usually are the ones lower on the BMI scale to begin with, and women who are high on the BMI scale usually tend to gain less. (However, there are plenty of exceptions to this!)

Fat women at greatest risk for large weight gains include those who develop complications like pre-eclampsia (where fluid retention is a common symptom and distorts total weight gain), and those who have dieted recently or who are chronic yo-yo dieters.

Women who diet chronically or lose a large amount shortly before pregnancy may gain extreme amounts. This is probably because the 'rebound' phase that often occurs after dieting may be intensified by the pregnancy's need to have adequate fat reserves for later (i.e., if it feels 'starved' after dieting, so it overcompensates during the pregnancy).

[This is one of the problems with the common medical advice to lose weight before pregnancy; these women often then have tremendous weight gains in pregnancy afterwards. One big mom I knew lost over a hundred pounds before pregnancy, only to gain 80 of them back during the subsequent pregnancy. Another woman on my website lost 90 lbs. before pregnancy, only to gain back 65. It is questionable how healthy such wide swings of weight in such a short period of time.]

All in all, if you are a woman of size and eat normally and healthfully, nature will likely keep your weight gain slightly lower than women of average size. This may be because women of size already have fat reserves and don't need the extra reserves that other women tend to add in pregnancy. It may also be because many fat women (especially those with PCOS and/or hypothyroidism) find that pregnancy tends to increase their metabolism.

Gaining too much weight may cause problems in pregnancy, so women of size should try to avoid excessive gains, but nutrition always trumps weight gain. A larger weight gain may simply be a variation of normal for some women; as long as they are eating healthfully and getting regular exercise it may not be a reason for excessive concern. It is certainly not a reason to put a woman on a diet in pregnancy or to schedule an automatic cesarean.

Remember, women of size do seem to have a wide variation of "normal" gains, depending on a variety of factors. Trying to manipulate weight gain through extreme means in order to meet artificial guidelines is probably an unrealistic pursuit, and possibly even be a dangerous one.

The best course is probably to eat healthily, exercise regularly, and let nature take care of the rest.

Saturday, July 19, 2008

Obesity and Weight Gain in Pregnancy, part 2

What Are Fat Women Being Advised About Weight Gain?

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 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 [170]. 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!

Obesity and Weight Gain in Pregnancy, part 1

Part One - Weight Gain Guidelines

So how much weight should fat women gain in pregnancy? That's the real question here, and one which has been hotly debated for many years.

Dr. Raul Artal, director of the "Bariatric Obstetrics" clinic in St. Louis, believes that fat women should gain very little if ANY weight and maybe even lose weight in pregnancy (with medical supervision). He's been putting out press release after press release in the last several years, pressuring the Institute of Medicine to lower the weight gain guidelines for everyone, but especially for fat women.

The Institute of Medicine's current guidelines for weight gain in pregnancy are:
  • Underweight women: up to 40 lbs.
  • Normal weight women: 25-35 lbs.
  • Overweight women: 15-25 lbs.
  • Obese women*: at least 15 lbs.
However, these may soon be under review, and if Dr. Artal has his way, revised downward for all groups. But should they be?

The first question do they figure out how much weight a woman "should" gain in pregnancy, anyhow? Typically, they estimate how much weight the baby will weigh, how much the placenta and amniotic fluid weigh, how much increased blood volume there will be, etc., then add all those up. The total should be about what women "should" gain in pregnancy.

Most sources also factor in some "fat storage" as normal, to be used as energy reserves during the birth, immediately post-partum, and during breastfeeding. Other sources (like Dr. Artal) do not believe that there should be ANY fat storage at all.

“We’re not bears,” Artal says. “Pregnancy is not a time of hibernation.”

So there is a major difference of opinion among experts whether pregnant women "should" put on any fat stores or not. Some believe it's part of nature's preparation for the demands of birth and breastfeeding, while others contend this was only for times of famine, so there is no need for additional fat storage. Of course, because fat women already have fat stores, they are viewed as not needing those reserves at all.

Now you'd think all the sources would pretty much agree on the total weight of each of these components (minus the fat storage issue), but they don't. Each has slight differences, but we can compare some common guidelines.

MSNBC has a chart they use to describe "Where the Weight Goes in Pregnancy." It breaks down the weight gain as follows:
  • Developing fetus 7 to 8 pounds
  • Placenta 1.5 to 2 pounds
  • Amniotic fluid 2 to 2.5 pounds
  • Increased uterine size 2.5 to 3 pounds
  • Breasts 2 to 3 pounds
  • Increased blood volume 3 to 3.5 pounds
  • Normal water retention 3 to 3.5 pounds
  • Total 21 to 25.5 pounds
The website for consumers at one medical school quotes stats from the American College of Obstetricians and Gynecologists as:
  • baby: 7.5 pounds
  • maternal energy stores (fat, protein, and other nutrients): 7 pounds
  • fluid volume: 4 pounds
  • breast enlargement: 2 pounds
  • uterus: 2 pounds
  • amniotic fluid: 2 pounds
  • placenta: 1.5 pounds
  • This gives an average total of about 26 pounds
On the other hand, Dr. Artal comes up with different totals. According to interviews he's given for press articles, "Even for a normal weight woman, Dr. Artal recommends no more than 10 to 14 pounds of weight gain, just enough to account for the fetus, placenta, amniotic fluid, increased blood volume, and breast enlargement." [emphasis mine]

Hmmmm. His math seems kind of fuzzy. Let's see, going with low-end estimates from above....7 lbs for the baby, 1.5 lbs for the placenta, 2 lbs for amniotic fluid, 3 lbs for blood volume, 2 lbs for breasts....I still come up with a minimum of 15.5 lbs*, and that doesn't include any allowance for uterine size increase. I don't know how Dr. Artal comes up with his 10-14 lbs figure.....and that's for average-sized women! Fat women aren't to be allowed any of that, under his guidelines.

So then, let's think this through. If they now are going to recommend less than the basic 15 lbs. weight gain for obese women, where should we be taking this away? The baby? The placenta? The blood volume increase? The amniotic fluid? Which of these is not needed or excessive?

Oops, sorry, fat chicks, you're only allowed a one-pound placenta, a pound of amniotic fluid, and half a pound of added blood volume. No increase in boobs is allowed; you have enough to start with and everyone knows fat women can't breastfeed anyhow, right? And a 7 lb. baby? Forget it. You have to have a 5 pounder instead, at most.

Oops, but even then, fat women would still be gaining some weight, tsk tsk tsk. They're not supposed to be gaining ANY. So by insisting on NO gain (or "very little"), doctors are, in effect, insisting that fat women lose weight while pregnant. Is that really safe? And how, really, are they supposed to do that? Drink Slim-Fast? Why would nutritional requirements be ANY different for a fat woman during pregnancy than any other woman?

Of course, any negative effects of such restrictions are completely shrugged off. And that's the problem....doctors assume that these restrictions are beneficial for baby and mother, but are they really?

More on that in future posts.

*That's how the 15 lb. IOM weight gain guideline for obese women was probably derived. They allowed for the weight of the baby, placenta, and related fluids etc. No allowance was likely made for fat reserves, and everything was based on the minimum possible weight gain.

Wednesday, July 16, 2008

Bariatric Obstetrics, Part 2 - This Guy is Objective?

Previously, we discussed the New York Times article called, "Too Fat and Pregnant," and the emerging concept of "Bariatric Obstetrics," obstetric practices which specialize in fat women (and not in a good way).

First we discussed how "Bariatric Obstetrics" ghettoizes fat women into a high-tech, high-intervention protocol without actually questioning whether such an approach actually improves outcomes. We also discussed how many fat women have found that they actually achieve better outcomes and more humane births by choosing the midwifery model of care, yet this push towards "Bariatric Obstetrics" might keep fat women from being able to choose that kind of care.

Today, we begin to look at the controversial concept of limiting weight gain in "obese" women in order to prevent complications, and the main doctor pushing this agenda.

Before we get to that, fairness impels us to note that not all of the New York Times article was bad. They discuss having equipment that fits the women they see, like large blood pressure cuffs and scales that accurately weigh large women (many of whom previously had to be taken down to be weighed on the loading dock scales). Would that more obstetric practices realized the importance of proper equipment for people of size.

In addition, proponents of "Bariatric Obstetrics" strongly promote the idea of exercise during pregnancy for all women, fat or thin. As long this is reasonably done, this is a good thing, as research clearly shows that regular exercise before and during pregnancy can lower the chances for gestational diabetes, pre-eclampsia, and other complications in women of all sizes. [But please note that doctors are johnny-come-latelies on this issue! Midwives have been promoting healthy movement as prevention for pregnant women for years.]

All well and good, even though the tone of the Times article was certainly
sensationalistic, emphasizing women having babies at "400, 500, even 600 pounds," when in fact these pregnancies are still unusual. But like the headless fat torsos in media releases, if they can emphasize the most "extreme" cases, then they can ratchet up the condemnation level in the public and the medical community.

But then the article turns into yet another media spin for limiting pregnancy weight gain in women of size. They quote Dr. Raul Artal (cue boo, hiss sound effect), who is trying to pressure the Institute of Medicine (IOM) into lowering the guidelines for acceptable weight gain during pregnancy, especially for obese women.

Dr. Artal did a study (a flawed study, but that's a topic for another post) that found less pre-eclampsia and cesareans among obese women who gained less weight in pregnancy, so now he's spinning this SAME study many different times in the press in order to create the illusion of a preponderance of evidence for little or no weight gain in women of size. He is manipulating the media to convince doctors everywhere (and the IOM) that the guidelines really need to be lowered. Sandy of Junkfood Science calls this "Science By Press Release," an analysis of which can be found

Dr. Artal has been promoting this same campaign to change the IOM guidelines for several years now. He seems to feel that with enough repetition, the message will create enormous pressure to change the IOM guidelines. So he keeps re-issuing the same old material in new ways, keeping it in the public eye, and more importantly, in the eyes of the doctors who influence the IOM, which is currently reviewing the evidence for these very guidelines.

But who is this guy, and what does he believe about fat women? Here's what Dr. Artal said in an earlier Associated Press article about limiting weight gain in pregnancy.

Although most doctors would never recommend dieting during pregnancy, Artal says he has no qualms about counseling overweight patients to eat less. "For them, less could still be the diet of another person for a whole week," he says.

[Amazing how this man is so psychic he knows without looking how much all these fat women are eating at all times. I'm always amazed when doctors insist they know what someone must be eating, based on their size alone.]

Do you really think that fat women are going to get respectful, dignified, fair treatment from this man? Do you really think he has the best interests of fat people at heart? Or he is so biased by his own fat-phobic assumptions about obesity that he can't possibly be objective about his own interventions?

The New York Times article does point out, "Some scientists warn that we still know little about the potential dangers of this approach," right before it shrugs off those concerns. Dr. Artal's guidelines are seen as a bit extreme by some doctors, yet few are speaking out against them.

This guy is now the Chairman of Obstetrics and Gynecology at St. Louis University in Missouri, and the director of the Bariatric Obstetrics Clinic there. So now he is spreading his message of fat-fear and extreme interventions to next generation of doctors everywhere.

Is this really the guy we want driving public and medical opinion about obesity in pregnancy? Where are the opposing voices in the medical and midwifery community, willing to speak out against this tripe?

Bariatric Obstetrics, Part 1

Bariatric Obstetrics is the new term some doctors have invented for practices that specialize in seeing fat women during pregnancy and birth. The New York Times just did a big article on this, called "Too Fat and Pregnant." (Pbbbttthhhh to the editor who came up with that title.)

But is "Bariatric Obstetrics" a good idea? Doesn't it just "ghettoize" fat women? It punishes them for being fat by limiting their weight gain (or even telling them to lose weight while pregnant), and targets them for extensive interventions all through pregnancy because they're assumed to be "so high-risk." It makes a cesarean and/or complicated delivery practically a self-fulfilling prophecy. And most of these women then get pressured for significant weight loss after the pregnancy, using whatever scorched-earth techniques du jour the clinic favors, ignoring the role that yo-yo dieting plays in increasing long-term weight.

And has anyone even studied whether this high-tech, high-intervention approach to birth in fat women actually improves outcome? Or do they just assume it must? The truth is that these interventions go almost unquestioned in obstetrics today, with pressure to do more and more, despite lack of proof that these are free from harm.

Unfortunately, "Bariatric Obstetrics" is a concept that is only going to get more and more wide-spread, until most average doctors will be pressured to refer all their fat patients to these "specialists," and most midwives will be forbidden to attend women of size at all. This is already happening: anecdotally I am hearing of this more and more often now. All without any proof that this approach improves outcome and is not harmful. And all while taking away the possibility of CHOICE for fat women in determining the kind of care they prefer to receive.

I understand the concept behind "Bariatric Obstetrics," and I'm sure most of the doctors involved think they're doing fat women a favor by creating practices just for their needs. Most doctors aren't bad people, just people trained into a mind-set around obesity that is so extreme they can't even begin to question what they are taught. Some genuinely want to help, and have been taught that this approach, in all its extremity, is the best way to do so. But the road to hell is paved with good intentions, and policies undertaken with the best of intentions often still lead to poor outcomes and discriminatory treatment in the end.

Most of the doctors in these clinics cloak their practices under of false banner of fat-friendliness by promising equipment that fits larger people, bigger chairs in the waiting room, understanding nurses, etc. They probably go out of their way (like weight-loss surgeons and diet companies) to do the fat-support double-talk, where they SEEM like they are fat-friendly and only doing this in YOUR best interests, REALLY. They only want to HELP you have a healthy baby, TRULY. And they might even mean it.

But the reality is that, whatever their intentions, they are perpetuating fat bias, discriminatory policies, and scorched-earth interventions. As with fen-phen and orlistat and weight loss surgery, in the end, fat people often end up worse off than they started. Only now they're doing it to fat people's babies too.

The premise of these practices are based SO much on fat-phobia and mistaken beliefs about obesity (fat people all eat too much and the wrong foods, they never exercise, they are at extreme high risk for problems, they are a danger to their poor babies, they have to be taught different habits for the sake of the children, etc.) that it is doubtful they can provide objective and respectful care for these women. And the fact that more and more fat women will be railroaded into this type of care, restricted from access to any kind of "alternatives," is especially frustrating.

Although they are not publishing them, I'd bet the cesarean rates and induction rates at these bariatric clinics are practically off the charts. However, then they'll just blame those high rates on the effects of obesity ("See how high-risk they are?"), rather than actually looking to see whether their policies had anything to do with that or not. Convenient, no? All while getting to charge insurance companies more and more money for such specialized care, and all while racking up more and more billable interventions for their clinic/hospital. "Bariatric Obstetrics" is going to be a profitable sub-specialty indeed.

The best way to fight against this mentality is to opt out of the medical model altogether. Your best bet for size-friendly care in pregnancy, frankly, is a midwife instead of a doctor. Although there are good and bad in every profession (not every midwife is size-friendly, and some doctors really can be size-friendly), midwives in general are much more size-friendly than doctors, especially in this current climate of extreme intervention around obesity. And your chances for induction, cesarean, episiotomy, and many other interventions are also much lower in general with a midwife.

If you are pregnant and looking for a care provider, don't let them bully you into this model of extreme intervention and fat-phobic care. Just because you are fat does NOT mean you "need" to see a high-risk specialist. Just because you are fat does NOT mean you need every prenatal test in the universe, or to be induced early for a "smaller baby," or to have an automatic early epidural or internal monitor placed, or to be pressured into a c-section "just in case." Just because you are fat does NOT mean you have to go to a "Bariatric Obstetrics" clinic.

In fact, unless there is some special complication that necessitates closer care, your best bet is usually midwifery. Anecdotally, many fat women have found that they have had much better births (with much better outcomes) when they saw midwives instead of OBs for their care. I certainly found this to be true, as have many other fat women I know.

Too Fat and Pregnant? Bariatric Obstetrics? Just say NO.

Saturday, July 12, 2008

"Prevent Cesarean Surgery" Video

This is a great video about why cesareans should not be done casually or without real necessity. It also discusses ways to lower your risk for having a cesarean.

This video is definitely worth your time to watch, even if you are not intending to become pregnant any time soon (or ever). Too few people realize the real risks of cesareans or the implications of the rapidly rising cesarean rate. In particular, cesareans impact fat women disproportionately, so it is an issue of great importance for fat-acceptance activists.

Here are some excerpts from the short description on YouTube:

Prevent Cesarean Surgery is a short inspirational and entertaining production. Using real quotes spoken by women who have had both a cesarean and vaginal birth, music, photography, and statistics, it presents invaluable information that is research-based.

All women of childbearing age will benefit from this educational movie. It is a must see! Cesarean rates in the United States are at a record high for both new and experienced mothers. Despite vast amounts of research regarding the increased risks for both mothers and babies who experience cesareans compared to vaginal birth, there is a growing acceptance of this surgery in our culture.

This movie addresses the question "Why should we try to avoid unnecessary cesareans?" It also presents advice for how to increase the chance of having a normal safe vaginal birth based on recommendations from organizations such as the World Health Organization, Lamaze International, and the Childbirth Connection.

Wednesday, July 9, 2008

Breaking Free of Dieting

I'm going to rant here a bit. I may say some stuff that might challenge some people's beliefs. You don't HAVE to buy into my beliefs if you don't want to. But I want to at least present a different way of thinking to consider, a step outside the paradigm. Consider it and really think about it. If you think it's totally wrong then, okay! Maybe this is not for you, maybe this is only for me.

But I believe with all my heart that the cycle of yo-yo dieting, of losing and regaining weight plus a little bit more, of doing it over and over again through the years, of having to "graduate" to more and more radical diets/drugs/surgical interventions over time to try to lose that weight is tremendously destructive and unhealthy. For some people I think it becomes almost like an addiction. However, it's difficult for people to step back and see the emotional patterns of the dieting addiction, it's so ingrained. If you look and consider seriously and disregard, that's okay. But take some time and do some serious soul-searching and questioning first.

The diet/binge cycle is so poisonous to your soul. You feel crappy about yourself so you go diet. You feel great while you start, you feel really great when you lose, you get frustrated as the loss plateaus and won't budge, you get pissed and depressed as the weight loss ends and starts regaining, you feel deprived of all the foods you miss that everyone else can have, then at some point you end the diet and give up. Perhaps you binge on the forbidden foods, perhaps you don't. Either way, you feel crappy about yourself, you eventually regain lots of weight, you may give up exercising, you feel worse and worse about yourself, you "stuff" that feeling (either emotionally or sometimes, for some people, with food), you feel even worse. You blame everything on your weight, you feel so absolutely disgusted with yourself that you finally re-start the dieting thing again, only this time a more desperate or stringent form of dieting than before in hopes that THIS one will be the one to work-----and the cycle begins again.

The disgust with yourself and the shame and self-hatred is an integral part of the diet/binge cycle. It propels you into the next diet. The dieting yo-yo sometimes seems like another, looooooonger version of bulimia---binge and purge, binge and purge----only you are bingeing on dieting. Some people feel crappy about themselves and self-medicate with alcohol or drugs or gambling or food or whatever. Other people self-medicate with dieting. That may sound strange, but as I observe others over the years going through the yo-yo dieting cycle again and again, it really seems true.

The shame and self-loathing you may feel is an important part of that cycle. Chronic dieters get addicted to the tremendous high of the weight loss and new clothes and improved treatment from others etc. It can feel GREAT to have that high, just like with drugs......but there's always a price to be paid afterwards.

Strange as it sounds, I also think some people get addicted to the lows afterwards when it fails and your high comes crashing down. Chronic dieters love to commiserate about how awful they are, how disgusting their behaviors or bodies are, how horrible they are to stuff their emotional issues with food, how broken and disgusting their bodies are. The self-hate talk I hear in this stage is just so sad, so soul-crushing, so self-wallowing.

Chronic dieters eventually resort to more and more desperate ways to try and lose weight. They turn one by one to unhealthy diets, fasts, very low-calorie diets, drugs, even gut-rearranging surgery. They get bigger highs with more dramatic weight losses, and lower lows from dramatic regains. It's like an addict---forever looking for a better high, no matter what the lows are afterwards, no matter the toll the addiction takes on your body and your psyche. It's the ride that they need.

Break free of the cycle! You don't have to be tied to it forever. Step out of the drama. Empower yourself about learning to love your body, whatever size it is. The first step is to recognize the patterns that chronic dieting creates in your psyche and just how destructive (yet seductive) they are, and how much power they hold over your life. The self-loathing is a big part of it.

Step outside the box for a moment. Ask yourself how your diet highs and self-loathing lows are serving you. Surely they are reinforcing an important belief about yourself or you wouldn't keep putting yourself through that. Ask yourself if you still need to keep believing these things or if you are able to let that paradigm go, even just a little. You don't need to fix these things overnight; just starting to recognize the underlying fears that drive you to dieting helps.

Sometimes it's the fear of what happens if you were to give up dieting that keep us in that cycle of self-destructiveness. Are you afraid that if you stop dieting your weight will balloon out of control? Are you concerned that you would then eat all the "bad" foods out of control and gain a ton of weight? The hard truth is that as people let go of the dieting mindset, sometimes they do over-eat. But once they realize that all foods are available to them, forever, they no longer have to over-indulge because another diet/famine period isn't coming. In time, they will self-regulate their eating so that they can enjoy "treats" without overindulging, so that they can balance their eating without feeling so restricted or denied. In time, most people will normalize their attitudes and consumption of food, once they feel secure about food availability. Most people will be healthier in the long run by letting dieting go----but it can be a leap of faith to do so.

What about people with true eating disorders? Some fat people do have true eating disorders, usually either bulimia or a true binge eating disorder. The dieting mentality only serves to reinforce and worsen these behaviors over time. Dieting makes an eating disorder worse, not better.

However, breaking out of the dieting cycle won't necessarily cure these eating disorders either. Until the person does the internal emotional work of identifying and healing the difficult emotional issues behind true eating disorders, the behaviors won't disappear and food will continue to hold too much power over them. Eventually many of these people turn to extreme weight loss schemes like diet drugs, extreme exercise, very low-calorie diets, or weight loss surgery in a desperate attempt to once again self-medicate. But in the end, these often fail too, and much or all of the weight is gained back. The bottom line is that the root of a true eating disorder is emotional and until that problem is addressed, nothing else will fix the problem.

But many fat people do not have true eating disorders. They may not always eat perfectly, but many poor eating patterns are actually artifacts of the binge/diet mentality. Eliminate the dieting cycle, and slowly the poor eating patterns disappear because they are no longer needed. Also the dieter's need for strict nutritional perfection will diminish over time, so the emphasis moves away from self-flagellation over eating a "bad" food and towards an emphasis on overall eating patterns over time, emphasizing the big picture on health and making positive changes accordingly, rather than micro-managing every bite and obsessing about it.

The "Oh heck, I've blown my diet so I guess I'll have another doughnut" mentality is part of the illness of the dieting cycle. It's total nutrition perfection or total food anarchy. One is the opposite mirror of the other. You only gain freedom from it when you step out of the paradigm.

Stepping out of the dieting paradigm is finding the empowerment to be reasonably healthy in your habits without having to be rigidly perfect, it's finding the ability to love yourself and be healthy at your current size, it's letting your body self-regulate and find its own natural size, it's recognizing the body hatred that you've internalized from elsewhere and working to transform it, it's being willing to step out of the diet cycle and stop believing that having good things depends on losing weight. In short, it's reclaiming your sanity and reclaiming your health and reclaiming your LIFE.

For some people the transition to more healthful and conscious eating is relatively effortless, and for others it can take time and much conscious effort. It's okay for size acceptance to be a "work in progress." Dieting mentality behaviors are not acquired overnight and it can take time to normalize them. But it can happen. Take the little steps on the path towards freedom and you will get there.

Break free of the hypnotic power of self-loathing. Break free of the addictive power of the highs and lows of dieting. Consider stepping outside the limiting "my body is broken" paradigm. Choose health and choose sanity. Choose the Health At Every Size paradigm.

Whether or not your body stays forever at this size or self-regulates to some other size, SELF-LOVE STARTS NOW. Here, now, at THIS size....with all its perceived imperfections.

Empower yourself. Love your body, love yourself. Let yourself be healthy---healthy in a new way to your mind perhaps, but healthy nonetheless---both mentally and physically and emotionally.

There are other ways to live than the dieting mentality, if you choose to. Self-acceptance starts NOW. You can do it.

Tuesday, July 8, 2008

Is HAES Unhealthy?

In the past, critics have charged that the HAES approach was unhealthy and would harm the health of participants. But a two-year long U.C. Davis study, published in the June 2005 issue of the Journal of the American Dietetic Association (as reported by Medical News Today) found that the Health At Every Size approach actually produced better long-term health benefits than a traditional dieting approach.

Members of the dieting group were told to moderately restrict their food consumption, maintain food diaries and monitor their weight. They were provided with information on the benefits of exercise, on behavioral strategies for successful dieting, and on how to count calories and fat content, read food labels and shop for appropriate foods.

Participants in the non-dieting group were instructed to let go of restrictive eating habits associated with dieting. Instead they were counseled to pay close attention to internal body cues indicating when they were truly hungry or full, and to how the food made them feel. They also received standard nutritional information to help them choose healthful foods, and participated in a support group designed to help them better understand how culture influences the experience of obese people and to become more accepting of their larger bodies. In addition, they were encouraged to identify and deal with barriers, including negative self-image, which might get in the way of enjoying physical activity.

The study spanned two years, with each group meeting for 24 weekly treatment sessions and, after that, for six monthly optional support group meetings. They also attended five testing sessions...At the testing sessions, factors such as blood pressure and cholesterol levels were measured. The participants' levels of physical activity also were evaluated, as were their eating behaviors and attitudes toward weight, body shape and eating.

Study results: Almost all (92 percent) of the non-dieting group stayed in the study throughout the treatment period, while almost half (42 percent) of the dieters dropped out before finishing treatments. This reinforces another message of the research -- that in the long run, people are much more likely to stick with a non-diet than a diet.

When the researchers tallied the results from the participants who completed the study, they found that:

-- The non-dieters maintained their same weight throughout the study. The dieting group lost 5.2 percent of their initial weight by the end of the 24-week treatment period, but regained almost all of it by the end of the two-year study.

-- The non-dieters showed an initial increase in their total cholesterol levels, but this significantly decreased by the end of the study, as did their levels of LDL cholesterol or "bad" cholesterol. The dieters showed no significant change in total or LDL cholesterol levels at any time.

-- Both groups significantly lowered their systolic blood pressure during the first 52 weeks of the study. By the end of the study at 104 weeks, however, the non-dieters had sustained this improvement, while the diet group had not.

-- By the end of the two-year study, the non-dieters had almost quadrupled their moderate physical activity. The dieting group had a significant increase in physical activity right after the treatment period ended but had slipped back to their initial levels by the end of the study.

-- The non-dieters demonstrated significant improvements in self-esteem and depression at the end of the study, while the diet group demonstrated a worsening in self-esteem. The dieters' depression levels initially improved but then returned to baseline.

In summary, while the non-dieters did not lose weight, they succeeded in improving their overall health, as measured by cholesterol levels, blood pressure, physical activity and self-esteem. The dieters, on the other hand, were not able to sustain any of the short-term improvements they experienced and worsened in terms of their self-esteem.

So the Health At Every Size approach can be healthy. While it may seem that dieting to lose weight is healthier, for many people the HAES approach results in better health in the long run.

And that's the most important thing, after all. As Kelly Bliss (author and exercise maven) suggests:

I propose that we END the “War on Obese People” and BEGIN “A Campaign for Healthy Eating and Fitness for ALL People, of ALL Sizes.”

Sunday, July 6, 2008

The "Health At Every Size" Paradigm

Many people think in extremes when thinking about weight issues. Either a person is fit and healthy and "normal-sized," or they are fat, unhealthy, sedentary and eating excessively.

However, there is a different approach in the fat-acceptance movement. This is the "Health At Every Size" paradigm (HAES). This approach rejects dieting to lose weight to fit into the narrow definitions of "normal" weight, but it doesn't mean "giving up on yourself" either. Instead, it is a weight-neutral approach to good health, focusing on behavior and self-concept instead of on the number on a scale.

The Health At Every Size paradigm emphasizes accepting and loving yourself as you are, learning to enjoy and practice physical activity regularly (but for the joy and health of moving, not as a means to weight loss), normalizing eating to eliminate restriction/over-indulging as a person moves toward a more physiological response to hunger, and focusing on overall health in mind and in body.

The Wikipedia entry summarizes it succinctly. The major components of HAES, as described by Jon Robison, are:

  • Self-Acceptance: Affirmation and reinforcement of human beauty and worth irrespective of differences in weight, physical size and shape.
  • Physical Activity: Support for increasing social, pleasure-based movement for enjoyment and enhanced quality of life.
  • Normalized Eating: Support for discarding externally-imposed rules and regimens for eating and attaining a more peaceful relationship with food by relearning to eat in response to physiological hunger and fullness cues.

The entry continues:

HAES advocates generally do not believe that the same narrow weight range (or BMI range) is maximally healthy for every individual. Rather, the HAES approach is that as individuals include physical activity in their lives, and eat in response to physical cues rather than emotional cues, they will settle towards their own, personal ideal weights. These weights, however, can be higher or lower than those described by standard medical guidelines.

The HAES size approach recognizes that people come in all shapes and sizes naturally, and that some people will never fit into the "normal" weight ranges as they are currently defined, despite leading perfectly healthy lives. Instead, the HAES approach redefines "ideal" or "normal" body weights. From
Instead of defining healthy weight with numbers, charts or BMI, it is defined in terms of the natural diversity of weight. Steven Hawks and Julie Gast, associate professors at Utah State University, define healthy weight as the natural weight the body adopts, given a healthy diet and meaningful levels of physical activity
The Health at Every Size movement embraces the following concepts:
  • Accept and respect your own and others’ unique traits and talents; celebrate diversity.
  • Healthy lifestyle is achievable for everyone, unlike so-called “ideal weight.”
  • Enjoy physical activity every day, your own way, as natural and beneficial.
  • Enjoy eating well; rediscover normal eating — tune in to hunger, appetite and fullness.
  • Enjoy full nutrition without dieting; honor balance and variety; all foods can fit.
  • Focus on wellness in body, mind and spirit, on overall health and well-being.

An excellent summary of the HAES paradigm is at Another summary of the HAES tenets is at They summarize it as:

  • Health enhancement—attention to emotional, physical and spiritual well-being without focus on weight loss or achieving a specific “ideal weight”
  • Size and self-acceptance—respect and appreciation for the wonderful diversity of body shapes and sizes (including one's own!), rather than the pursuit of an idealized weight or shape
  • The pleasure of eating well—eating based on internal cues of hunger, satiety, and appetite, rather than on external food plans or diets
  • The joy of movement—encouraging all physical activities for the associated pleasure and health benefits, rather than following a specific routine of regimented exercise for the primary purpose of weight loss
  • An end to weight bias—recognition that body shape, size and/or weight are not evidence of any particular way of eating, level of physical activity, personality, psychological issue or moral character; confirmation that there is beauty and worth in EVERYbody

More on Health At Every Size (HAES) in future posts..........

Wednesday, July 2, 2008

Low Vitamin D Levels Common in Fat Folk

At times, I will be blogging to raise awareness of certain health conditions, ones that may be more common among people of size....and especially ones that people of size may not know to look for.

One such condition is low vitamin D levels. Several recent studies have suggested that at least 50%......HALF!!!....of all "obese" folks may have low vitamin D levels.....levels low enough to significantly affect their health, both now and in the future.

Yeah, that vitamin D. Vitamin D, as is in the stuff you get from exposure to the sun. Vitamin D, as in the stuff that's added to milk or some types of orange juice. Vitamin D, as in the stuff that's important for bone health, but may also be related to high blood pressure, diabetes, heart disease, multiple sclerosis, musculo-skeletal pain, colon cancer, breast cancer, prostate cancer, and early death.

Fat people, people of color, those living at more northern latitudes, those who are insulin-resistant, older folks, and those who follow "fully covered" clothing traditions are at a higher risk for low Vitamin D levels. So are those folks who have fat-absorption or intestinal issues, like cystic fibrosis, Crohn's Disease, or those who have had gastric bypass. But make no mistake......even skinny white folk living in sunny areas may have low Vitamin D levels. It seems to be that common now.

Rickets used to be a serious problem in the past. But because milk is fortified with Vitamin D now, many medical professionals assumed for years that Vitamin D was not an issue anymore. But in this age where we are encouraged to slather on the sunscreen liberally, low Vitamin D levels may be increasing.

What's clear is that low Vitamin D levels seem to be associated with a number of health conditions. What is less clear is whether supplementation with Vitamin D (either through vitamin supplements or through increased sun exposure) is able to treat or prevent these health conditions. Furthermore, too much sun exposure may lead to skin cancer. So it's hard to know exactly what to do about low vitamin D levels.

But the first step is to find out WHAT your vitamin D levels are, especially if you have one or more of the risk factors listed above. It's best to test for this during the wintertime when your sun exposure is at its lowest level (and what you do get is not absorbed very well). If you test in the summertime and are borderline at all, be sure to re-test again in the wintertime.

When you are tested, be sure to ask for your exact results AND the scale that was used to determine "normal." One thing I have noticed in looking at this issue online is that different sources define "low" vitamin D levels differently (and different sources use different units of measurement). Some doctors define "low Vitamin D" levels so conservatively that hardly anyone qualifies; some define it so liberally that lots of people qualify. So get your exact results, see how it compares to the lab's range of "normal," and then find out how their "normal" compares to online measures. Get some perspective on how much room for concern there really might be.

If your Vitamin D levels do turn out to be low, you can increase your intake of Vitamin D-rich foods, like eggs and fatty fish, or Vitamin-D fortified foods like milk or some orange juices. This is probably not the best way to correct a significant deficiency, but when possible, getting nutrients from real foods instead of supplements is usually optimal.

Many healthcare practitioners currently recommend Vitamin D supplements (vitamin D3, cholecalciferol), though how much is needed is hotly debated. Current recommendations are about 200 international units, and most multivitamins typically contain about 400 international units........but many providers believe this to be far too low. About 1000-2000 international units seems to be considered relatively safe, and some healthcare practitioners recommend up to 4000 units for those who are Vitamin D-deficient. Some practitioners recommend even more, while others dispute the safety of larger doses. Research on optimal dosing is urgently needed, and on whether D supplements actually help or hurt health.

Another controversial issue is sun exposure. Many doctors are now recommending that people get about 15 minutes of sun exposure (no sunscreen) every day or two so that the body can synthesize its own Vitamin D from the sun, which is the most efficient source of all. 15 minutes sounds pretty minimal; some healthcare providers recommend more, while others balk even at suggestions of 15 unprotected minutes.

The best course for sun exposure has yet to be determined, but personally, it makes sense to me that if we evolved in an area of high sunlight intensity (Africa), we were made to need regular sunlight exposure. Covering up so much (hats, long sleeves, sunscreen everywhere at ALL times) seems a bit extreme to me. I agree we shouldn't overdo sun.....but it seems to me like the pendulum on sun exposure has swung too severely to one side. How about a happy medium? One that takes into account your geographic area, your skin color, your health status, etc.? Might some limited sun exposure be reasonable and even helpful for some people?

At this point, I don't think that scientists have fully proven their case about low Vitamin D levels. It may be that low D levels is just the latest scientific "fad" explanation for all the ills of the world. We need more research to prove their point. On the other hand, at this point evidence suggests that low D levels are associated with a number of health conditions. Whether low D levels are simply a symptom of something else or are the actual cause of health problems remains to be seen, as does whether supplementation or increased sun exposure decreases/prevents these health risks.

At this point, it's hard to know what is best to do. However, because many "obese" people tend to be insulin-resistant and have particularly low vitamin D levels, it may be most prudent for us to get tested, and to consider either supplements or modestly increased sun exposure if the tests show a Vitamin D deficiency.

Post Script:

It's interesting how vitamin D levels bring out subtle size biases.

When I was diagnosed with severely deficient levels last fall, my provider asked me if I thought the deficit was because I wasn't getting enough sun. Implication: You must be a couch potato and therefore you probably rarely get out in the sun. Even friends asked me if I thought this was the real cause.

Come on, people! Research shows that the decreased levels of Vitamin D in obese people is not due to lower intakes of calcium/vitamin D foods, nor is it due to low sun exposure. So there!!