Saturday, July 19, 2008

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.


Anonymous said...

This is absolutely ridiculous. Here in the UK, my pregnancies have been under midwife-led care, and I was only ever weighed once during all three of my pregnancies (the first, six years ago). My midwife told me she wouldn't even blink if I had gained up to 40 lbs during my pregnancies.
I had healthy babies, but they were all very big -- 8lbs and two 10 pounders.
Every woman is different, and every pregnancy with each woman is different. "Recommending" arbitrary numbers with weight gain is just going to cause unnecessary stress with expectant mothers.
"We are not bears"? What a scientific conclusion, doctor! Women have gained weight through pregnancy since time immemorial. Creating a life and nourishing that life after it's born are very hard on the body.
Will the medical community ever cut us some slack? It doesn't appear so. Our weight seems to be available for judgment from birth to death, in sickness and in health.

Anonymous said...

jamboree touched on what really struck me. What about women who have big babies? My first was 9 lbs. Add all the rest of it, and you're talking probably 20 lbs. minimum.

(This is another example of how I happened to have been lucky with my pregnancies, because my first was the only one in which the doctor was concerned about my weight. But that was due to the pre-eclampsia I had, and the water weight gain I was experiencing (70 lbs. at the end). Not because I was just a fat fatty that couldn't stop shoveling in the donuts.)

You know, "they" like to pin all the blame on this stuff on obese women, basically assuming that they just stuff themselves all day long (after all, they have an EXCUSE now!!). But I'd be willing to bet that if "they" were to study some native tribe somewhere and monitor the women's pregnancies, they'd find out that a 15-25 lb. weight gain at minimum was NORMAL for a pregnant woman. I'd seriously put money on it.

Naomi Miller said...

I've also looked for, and not been able to find, a reason why "excess" (whoever gets to define that) weight gain is a bad thing. What risk factors does it introduce?

And why did nobody tell me that fat women can't breastfeed? It's a miracle my first survived nutrient-free for almost a year, and my second has grown so much on an all-air diet.

Anonymous said...

I do not think that pregnant should be pressured to lose weight under any circumstances. But I have heard of women with PCOS losing weight during early pregnancy and ending up with a very small net gain, without delibarately dieting. I'm part of a message board for PCOSers and I have read of this quite a bit. This makes sense really since PCOS is a hormonal condition and the hormones which normally make it incredibly difficult for a woman with PCOS to lose weight are different during pregnancy.

Anyway, it's hardly something I'm an expert on - quite the contrary - but I wonder if some of these obese women who lose during pregnancy are in fact PCOS women, who seem to find losing in pregnancy possible, but may well gain it all back soon after the baby is born. PCOS women are of course all told that losing weight is what will magically get them pregnant in the first place, but that's another story...

wriggles said...

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

I think it's important to remind Dr. Atal that doctors did not create the human body, they only minister to it. They just as much as the rest of us are subject to the ways it actually works, not the ways he thinks it should works. Therefore his views are just that, views. In fact even he for all his bombast still has to describe his dictats as guidelines that is, not biological but perameters that come out of their fears and frustrations. They will be as successful as their entreaties not to be a fatty in the first place.

As for that list, breasts should gain 2 or 3 pounds, I actually feel embarrassed for them, what exactly do they propose you do if your jubbs come in over very scientifically calculated limit?

Instead of creating constructs that promote more interventions, it's about time that more attention was paid to the caesarian scandal, where apparently modern women can barely pass a baby down the birth canal anymore.

This kind of thing will just help fuel that underground movement of give birth without medical interventions.

Unknown said...

Do women even have 7lb babies anymore? I've seen 6 babies born to friends in the past 6 years, and none of them were under 8 pounds-- and these were all vaginal births with no complications (no hypertension, preeclampsia, gestational diabetes, etc) in slim-to-average women in their 30s.

Basically, I don't think that doctors know nearly as much as they think they do.

Well-Rounded Mama said...

Anonymous: Yes, it is not unusual for many larger women to lose weight at first in pregnancy, then in the second/third trimester slowly gain that back to a small net gain. That's the topic for another post coming up in the series.

I was one of those women who did that, and yes I do have PCOS, although mildly compared to some. I think for some of us, pregnancy just re-sets the metabolism and we drop weight without trying at all in the beginning. I can feel the difference in my metabolism when I'm pregnant...and then again when I'm done.

But there's a wide variety of experiences of wt gain in women of size, and as you said, it's important that women not be PRESSURED into losing weight or not gaining if that's not something their body is cooperating with. Nobody should be dieting or trying to restrict intake. The baby NEEDS good nutrients.

More on this in a future post in the series! Also a post on *why* "excess" gain is considered so bad, especially in women of size, and several other things. It's a complicated subject, lots more to say about it! Keep reading and commenting.

Unknown said...

My cousin's doctor asked her how much weight her mother gained during her pregnancies. My cousin said "About 40 pounds," and the doctor said, "Then that's probably how much you'll gain." Sure enough, my cousin gained just under 40 pounds with both of her pregnancies--she had two very healthy babies and has since returned to her ordinary weight (which is at the high end of so-called "normal").

As long as the mom-to-be is active and getting adequate nutrition, I see NO reason to obsess over the amount of weight gained--and CERTAINLY no reason to advocate dieting during pregnancy!

April D said...

DH and I are considering children of late and having serious wonders about the entire process. I've been reading more and more on the whole thing; especially as it relates to fat women (thanks for the great info Well-Rounded!).

This post reminds me of a long while back when I would joke that if I ever DID become pregnant I would treat the little growing life as an alien and just force it to eat off my fat stores until I was skinny. Just typing it now makes me cringe but this is seriously how these doctors are acting; like the budding life inside of you doesn't deserve the nourishment it needs!

That a woman should be hoping STILL to diet (I can still remember reading on the South Beach diet websites how you could safely deny yourself vital nutrients up to a certain time while pregnant. Geesh) just boggles the mind.

It is just one more frightening thing in the list of hesitations about getting pregnant. Yikes.

Anonymous said...

I had a 10.5 pound baby, that exceeds his minimum weight gain right there. Foo on this foolish doctor. And, while it's true that women aren't bears, I don't see the relevance to weight gain during pregnancy. Pregnancy isn't hibernation, but that doesn't mean a few extra pounds are a bad thing.

Out of curiosity, does anyone have research on weight gain vs the health of the newborns? I'd bet that you'd find that the typical weight gain produced the healthiest babies.

It's also my impression that larger babies do better overall than small babies; not that some people can't have healthy small babies, but if the baby has been stunted for some reason, that's a much larger long term problem than a chubby baby.

And a final mention, there's research coming out that high levels of stress during pregnancy are bad for the baby. Dieting is a really stupid thing to force women to stress over, or make them worry if they're gaining too much.

Inanna said...

I want Dr. Atal to shut his yap until he gets pregnant and tries to control his food intake. Seriously, my experience has been that when I'm hungry, I'm hungry, I have to eat, and I have to eat what sounds good. Period. When I'm full, I can't stuff myself past that point no matter how yummy the meal. I'm just done. You couldn't have paid me a million bucks to exercise regularly during the first trimester. I work full time and was beyond exhausted.

Try to tell my animal body to do any different than what she needs to do, and she will bite you. And not in a good way.

MJK said...

I know this is an old post, but I've been reading through your archives and all I can say is... wow.

These MEN, telling us what is best for our bodies. OH wait that's how they like it to be.

I am so glad for this pregnancy I was able to find the services of a midwife who has been practicing for over 30 years and supports me in trusting my own body!