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!


Anonymous said...

I had to comment. I'm 5'2" and used to hover around 190-200. I then trained for a marathon and went to 170 pounds. Got pregnant during training (ran it at 3 weeks preg but didn't know yet!) and subsequently gained 80 pounds to 250. The doc was very respectful and didn't ever make me feel ashamed (though I did!). Next baby: started at 220, gained to 250 again. She is 4 years old and I'm around 230-240. I'm new to FA and wish I'd found it sooner!

Anniee451 said...

I essentially lost weight during my pregnancies, mainly because for the first three months I couldn't eat (no vomiting, but constant nausea) - just a sleeve of crackers per day and some ginger ale. Then for the last three months the heartburn was so severe that even a bite of food left me clutching my chest in agony. So I came out of the hospital weighing less than when I got prenant each time. I certainly don't advise it - if you can eat, you should! It's, um, healthy. You SHOULD gain weight, no matter how fat you are to start.

Luckily it was long enough ago that doctors apparently knew this. They never said anything about my weight except if I wasn't gaining enough. Well, with my son anyway; I wasn't fat when I had my daughter.

I've said it before, but I really feel for women having to go through pregnancy and birth in these fat-hysteria times. :(

Inanna said...

These posts are fantastic, and each one makes me so grateful for my midwife, who never mentions what I "should" weigh or how much I "should" gain (or lose, heaven forbid!). I weigh myself at each appointment (and do the urine sugar & protein check myself), and tell her what I've found out. I lost weight during my first trimester due to almost-constant nausea and vomiting, and now in my second trimester I'm slowly gaining. I'm perfectly healthy. I was worried, in my first trimester, that I wasn't getting good enough nutrition, because there were days when I didn't have more than Coke and saltines, and I couldn't look at a green vegetable, but my midwife wasn't worried. She said my experience was perfectly normal, that I ate well before I got pregnant, and I have plenty of time to eat well when I'm feeling better (which is now, fortunately).

I can't imagine trying to regulate food intake in any way during my pregnancy. I'm happy to find something to eat that appeals to me, and that I can keep down. I couldn't force myself to eat anything I didn't want to, and I can't let myself get too hungry. My animal body definitely seems to be in charge of this whole thing!

(Also, I tried WW a few years ago, and my understanding was that they didn't even allow pregnant women to follow the program, because pregnant women weren't supposed to be dieting.)

Willow said...

My last medically-managed pregnancy was more than 6 years ago now, thankfully, but the blatantly size-biased medwife I went to did her best in a few months to undermine everything believed about my body and its ability to grow a healthy baby. She lectured me at every visit about my "clearly dreadful" eating habits and made me keep a strict food diary. When I brought her my meticulously kept logs, she challenged them, accusing me of lying about my dietary intake. When I confessed an unusual craving for popcorn at 39 weeks, she snapped, "Well, stop it. Do you want a monster sumo baby?"

I netted a gain of 11 lbs in the pregnancy. My son weighed 10 lbs 5 oz. All these years (and a beautiful unassisted pregnancy) later, I'm still trying to undo the damage that horrible woman inflicted on me.

CJ Porter said...

I find it interesting to hear doctors telling people to go back to Weight Watchers. WW has a strict policy - if you're pregnant, you can't be in the program. The minute I told my WW leader I was pregnant, she pleasantly told me that my time there was done and she'd see me after the baby was born.

I am so thankful that I had an OB who was supportive and was on the "eat healthy, you weigh what you weigh" end of the spectrum!

Anonymous said...

With my first pregnancy, when I was 30, I started out somewhere around 250lbs (at 5'7") and wasn't gaining any weight. My midwife actually sent me to a nutritionist to make sure I was okay, even though I assured her I was eating well. I'm a vegetarian, and during that pregnancy, I developed a massively intense bread-aversion. I couldn't stand the smell of bread for the whole 8 months and even pasta sort of disgusted me. So by the end, I lost like twenty five pounds without trying. My first son came a month early, but was perfectly healthy.

During my second pregnancy, at age 34, I had no aversions but no particular cravings. I maybe put on about 15lbs tops. It was a pretty easy pregnancy, despite my chasing around a small child.

With my third pregnancy, at age 38 and with two kids and a full-time job, I had pretty icky morning sickness for a while, but no aversions and just an odd craving for egg salad and cold cereal at nights. I started out the pregnancy around 250lbs, and by the 9th month, I was up to 270lbs or so. My midwife made one comment about it, but it was just to watch my weight. I said, "I'm not doing anything differently, and I'm healthy, right?" She said, "Yes, everything's great!" And we moved on to talk about whether the little guy was likely to be fast delivery, being my third.

The midwife each time was respectful and recognized that pregnancies varied, that I wasn't thin to begin with, and most of all, especially with my third pregnancy, that I was an old hand at it. She knew I knew my body and what it could and would do.

In all three pregnancies, I had excellent blood pressure and perfectly good blood sugar. I had no complications at all, and I delivered vaginally (a misnomer, as vaginal births are whole body births!) in the hospital, with the midwife helping me along.

My advice to any fat pregnant woman is seek out a midwife who respects you and don't settle for less than that. My midwife never doubted that I could do it, and so I never doubted it either.

(And if you're in the NYC area, I highly recommend the Midwife Group at Beth Israel Medical Center. I live in Jersey City and drove into the City to give birth there twice).

Brigid Keely said...

Just wanted to say that your blog is a really valuable thing. Thank you so much for the time and effort you put into it.

Sarah said...

I'm currently pregnant with #2 and have gained 11 lbs so far. I track my own weight weekly at home (along with blood sugar) and report the results to my midwife. She has never lectured me about weight, but when I hadn't gained anything by 24 weeks she reassured me that she had a client once who only gained 10 lbs and the baby was fine - she was afraid I would be worried about not gaining weight! FWIW, I started this pg at 228 (I'm 5'6") so am def in the "morbidly obese" category according to whatever medical guidelines.

I haven't deliberately tried not to gain weight, but I have cut my sugar/refined carbs intake to control my blood sugar (ds was in the NICU for 2 days with low blood sugar after his birth - a situation I'd rather not repeat if possible). I've also been more active inthis pregnancy between chasing a toddler, nursing, and trying to reduce our carbon footprint by walking instead of driving.

Anonymous said...

With all three of my pregnancies, I never once heard anything negative about my weight (three different providers nonetheless). I also am almost 6 feet tall and carry my weight well (or at least I used too ;) This last pregnancy, my 12lb vba2c, I lost 20 or so pounds in the first trimester and gained that back, mostly at the end. The delivering doc, upon reviewing my records/us, couldn't believe I grew such a big baby "not having gained that much weight." I was actually 20 pounds lighter six weeks post partum than when I became pregnant. I can't say I was a super good eater during this pregnancy, but lots better than my second pregnancy.

Thanks for writing such a great blog. You are such a wealth of information and thanks for sharing with us!


Anonymous said...

i started out at 110 lbs for my first pregnancy and gained 90 lbs to end up at 200 lbs. I started out at 190 lbs for my second pregnancy and ended up at 190 lbs day before delivery. effectively losing 25 lbs. my OB seemed concerned that i was not gaining weight but did not push me too much. however, i have to say that i was much happier at the end of my second pregnancy than i was at the end of my first.

Anonymous said...

As a former med/pharm researcher,
I find it really strange how the entire medical community in the United States is well aware of it being well-documented over decades of longitudinal research that ANY dieting to lose weight, no matter how 'healthy' or 'careful' or 'medically supervised' the regimen, greatly increases blood serum levels of cortisol for the entire duration of the dieting and even after dieting stops. It is an unavoidable fact of any diet that elevated levels of cortisol in ANY adult can severely disrupt sleep, cause or exacerbate autoimmune disease, initiate cardiovascular damage, permanently damage a highly sensitive HPA (hypothalamic-pituitary-axis of the brain), and cause all sorts of other quite literally incurable and many times entirely untreatable lifelong health problems.

Now, how this relates to pregnancy and weight gain: dieting in and of itself is extremely stressful on all body systems and WILL raise your blood cortisol to well above baseline, for the long run. Now get this: ALL recent literature from the past 20 years of neonatal research from institutions such as the American Association of Pediatrics and the American Psychological Association point to the fact that elevated levels of maternal stress hormones in the mother's bloodstream during pregnancy can and WILL permanently damage any fetus, through inundating the fetus with levels of hormones that are quite literally toxic to the developing neuroendocrine and cardiovascular systems of the unborn child. For example, (in fetuses prior to 35 weeks gestation or 37 weeks of pregnancy) elevated maternal blood serum cortisol has been noted to have an EXTREMELY high correllation with a baby being later diagnosed in childhood with permanent brain disease such as schizophrenia, ADD, ODD. Also noted are the high prevalence of intrauterine, nongenetic development of diseases of the neuroendocrine and cardiovascular systems. In fact, 75% of mothers clinically documented to have elevated blood cortisol in the first and second trimesters and in the first half of the third WILL have a baby born with clinically significant signs of intrauterine stress toxin exposure.

Because there is NO WAY of avoiding elevated cortisol and other stress hormones in the blood during any restriction of diet, why would the IOM and Cedergren push dieting during pregnancy for ANY pregnant woman? It goes against 100% of all the peer-reviewed literature from the AMA, the NIH, the AAP and the APA.

It's a bit scary to think about the obvious facts that the IOM and Cedergren are both basically telling overweight and obese women to purposely induce permanent disease states upon their unborn children and cause themselves potential permanent physical harm by dieting and/or severely restricting weight gain through rigorous dieting in pregnancy.

Sarah said...

My first ob appointment I was told not to gain a single pound. The doc then proceeded to tell me while performing a Trans vaginal ultrasound on me (with my fiance standing by my side) that I need to join weight watchers. I can't even begin to express just how humiliating that was to me. I was absolutely devastated.

Anonymous said...

Virginia Beck. Kauai Nurse Practitioner. I thought I was a uniquely emotionally scarred woman until I found his site. My story is pretty horrific. I had always been about 140 pounds but recently gained about 40 pounds. I found out I was pregnant and from day 1 all that woman could comment on in our check ups was my weight. Forget WHAT I was eating ( nutribullet smoothies, salads and veggies) she proceeded to fat shame me. This lasted through my 8 week appt when she could not find a heartbeat and blamed me for my "fat stomach" as the reason I could not hear my baby's heart. I remember hysterically crying all the way home. 5 weeks later I went to see my obgyn who could not hear a heartbeat. HE sent me to a hospital for a transvaginal ultrasound where we learned my baby died at 7 weeks. I suffered sepsis, infections, hemmoraging, and and emergency d&c as a result. That HORRIBLE evil women blamed my weight instead of sending me right away for a transvaginal ultrasound and could have spared me weeks of agony.