Thursday, October 9, 2008

Putting the Baby on a Diet Before It's Even Born

Two of the most important questions in the "fat women should gain less weight in pregnancy" movement are:
  1. Exactly what means should be used to achieve that smaller weight gain (i.e. do they recommend hypocaloric diets to obese women in pregnancy)

  2. What will providers do to enforce a particular weight gain if a fat woman starts to gain more than allowed despite normal nutrition
The answers to these questions are very important.

Normal Eating vs. Hypocaloric Diets

When advising their obese patients to aim for a smaller weight gain in pregnancy, some care providers simply mean "Eat healthy and normally, exercise regularly, and if you don't gain much weight, that's fine."

There's nothing wrong with this approach. As we have established, many larger women don't gain as much weight in pregnancy regardless of what they eat. It's not outside the range of normal. As long as they are eating healthfully and not restricting calories, whatever they gain (or don't gain) is fine.

[Of course, part of the problem with some doctors is their assumption that fat women OBVIOUSLY eat poorly so therefore eating healthy must represent a major change in intake and lifestyle and so they won't gain much weight at all. I can't tell you how much those assumptions irritate me. But I digress.]

But when some doctors advise gaining less weight in pregnancy, they mean manipulating their clients' food intake in order to achieve a lower weight gain. They're not just talking about eating healthfully and normally, they basically mean prescribing hypocaloric diets in pregnancy.

And if their clients start to gain more than what is "allowed," some doctors use scorched-earth techniques to limit that gain.

This is why the movement to limit weight gain in pregnant obese women is most alarming. This is the course of action that is dangerous and must be questioned.

What Is Normal Caloric Intake in Pregnancy?

Of course, a discussion of all this depends on what you think is a normal caloric intake in pregnancy.

Most sources just say it's 200-300 calories beyond your normal intake in the 2nd and 3rd trimester. Many don't specify a total number, but simply note that 200-300 calories extra is all you need and that doesn't take much extra food.

The sources that specify caloric intake say slightly different things:

  • The National Institute of Diabetes and Digestive and Kidney Diseases says that normal pregnancy caloric intake can vary from 1900-2500 calories, depending on your activity level, height, and energy needs
  • The RDA/DRI for pregnancy is usually cited as 2400-2500 calories in books

  • The American Dietetic Association says that most pregnant women need 2200-2900 calories during pregnancy
So even "official" sources differ somewhat in the total calories needed during pregnancy but let's assume around 2400 calories; a bit less if you are not very active.

Calorie Intake for Obese Pregnant Women

But if women of average size are "supposed" to eat somewhere around 2400 calories, give or take a bit, how many are fat women supposed to have?

Well, few sources will tie themselves to recommending that fat women only eat "x" calories in pregnancy....most just strongly imply that fat women should be eating far less than the norm.

What happens most often is that doctors and pregnancy books tell women they should NOT gain much weight in pregnancy.....and then they leave it up to the mother to deduce how to achieve such a limited gain.

So even if a care provider doesn't directly say, "Eat only xxxx calories," the advice to strongly limit weight gain indirectly is going to lead to hypocaloric intakes in many women.

Some sources are not afraid to come right out and recommend caloric restriction to women of size. For example, fat women with diabetes or gestational diabetes are routinely advised to restrict their calories because borderline starvation has been shown to lower blood sugar. So there are some studies that show that women have slightly lower blood sugar if they are given hypocaloric diets.....but is this really harmless to the baby?

The degree to which obese pregnant women with diabetes or GD should be restricted is controversial. Many programs limit obese women to somewhere around 1400-1600 calories. Some have limited women to as few as 1000-1200 calories.

Non-obese pregnant women with diabetes/GD, on the other hand, usually are given at least 2000 calories and often more like 2400-2500.

Please note---that's 500 - 1000 calores less per day!

My question is....why would it take fat pregnant women less calories to grow a baby than average-sized women? Isn't the actual caloric/energy cost of growing a healthy baby going to be similar among women of all sizes?

Sure, obese women have fat stores already and so we don't need extra calories for building up fat stores. So I could buy a few less calories per day.....but 500-1000 less calories per day?

That is a lot more than the difference between a bit of extra fat stores or not. With that kind of restriction it's difficult to believe the mother is getting all of what she optimally needs nutritionally.

But it's not just GD mothers that are getting hypocaloric advice. Although such drastic cuts are by no means universally advised, it's still not uncommon for women of size to be given hypocaloric diets in pregnancy.

Here's a website....from a registered dietician no less!.....that recommends that obese women select her 1500-1700 calorie plan, while overweight women get to whoop it up on her 1800-2000 calorie plan. Whooohooo.

And it really isn't all that uncommon for obese women to be told to limit her calorie intake to somewhere in the 1500-1800 calorie range.

Real-Life Dietary Advice

But is this kind of restriction just the result of a few raving lunatics here and there, or is this kind of advice really common?

Here is a sampling of just a few of the emails I've seen over the years, documenting reduced caloric diet advice during pregnancy:

  • When I was pregnant with my first, [the doctor] had me on a 1800 calorie diet
  • My [relative] will be having her baby [soon]. They just tested her a few weeks ago and she says her sugar is "borderline." They put her on a 1500 calorie diet.
  • [At 22 weeks pregnant], the OB told me I probably had gestational diabetes. [He] suggested I go on a 1500 calorie diabetic diet.
  • While [pregnant] with *twins*, the nutritionist put me on an *1800* calorie diet
  • At our first meeting the nutritionist very patronizingly recommended we all eat as much aspartame as possible before introducing us to our new diet, one that I would later calculate to add up to roughly 1300 calories per day.
  • My fat-phobic OB...put me on an 1000-1100 calorie a day diet with baby #4

Although 1500 and 1800 calorie diets in pregnancy are most common, I have read studies (yes, recent ones!) where they had PREGNANT fat women on 1200 calorie diets! It's not common but unbelievably, it does still happen.

WHAT are they thinking?

The Scorched-Earth Approach

And the further question is, if women gain more weight than their doctor tells them they may gain....what then?

[Note: Some of these stories have been mentioned before, but they bear repeating in this context.]

Is she going to be harassed every time she gets weighed at the doctor's?

  • 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

Is she going to be sent to Weight Watchers or Jenny Craig in an effort to keep her weight gain down?

  • [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.
  • After meeting with the OB nurse, she said that I could go back to WW.
  • 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.

Is she told to diet during the last trimester of pregnancy when the baby is really developing neurologically?

  • I was told not to gain any more weight when I reached about 7½ months with my first 2 pregnancies. 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 have gained 18 pounds so far..[the doctor] had a fit. She told me...I had better lose weight. I asked, "Do you mean not gain any more?" and she said, "NO, you need to LOSE weight.”
  • [The doctor] said I mustn't gain more than 20 lbs., 15 was even better, because I was overweight. 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.

Is she going to be told to go to extremes in order to limit weight gain?

  • [The OB told me, while pregnant with twins, to drink Slim-Fast in order to keep down my weight gain.]

This is one of the most critical questions. What interventions are going to be used to curtail or prevent an "excessive" weight gain? And how can we be sure they are not doing more harm than good?


Let's be fair. Most doctors these days do not advise fat women to diet during pregnancy, but there is a movement afoot return to this, and some doctors (and even some midwives) are advising reduced caloric diets.

Furthermore, the common advice for obese women to gain minimally during pregnancy means that many of them will adopt reduced calorie diets during pregnancy in order to achieve that goal.

And if the Institute of Medicine (IOM) revises its weight gain guidelines (as they are currently considering doing), many doctors (and even midwives) will see this as a justification to put more and more obese women on reduced calorie diets.

And this sort of thing has the potential for far-reaching consequences.

You know that the obesity hysteridemic in this country is way out of control when they are, in effect, promoting putting the baby on a diet before it's even born.

Next: The potential effects of fetal undernutrition


Inanna said...

There is something in these posts about food and weight gain in pregnancy that really highlights for me how cruel all our standard approaches to food and calorie restriction are. Dieting is so normalized in our culture that I can sometimes forget how messed up it is. Imagine telling anyone, let alone a pregnant woman, that she isn't allowed to eat, that she must carefully monitor what she eats. It's really inhumane.

I'm in the 29th week of my first pregnancy, eating what I can eat and want to eat, and I look and feel really good. My midwife hasn't the slightest bit of concern about my size or weight gain, because that's not what matters. What matters is that I'm healthy. There is enough uncertainty and stress in big life changes like pregnancy; why should anyone add to that by trying to scare us and make us conform?

Anonymous said...

I'd think that larger women's bodies burn more calories than smaller women's bodies, and therefore they should be expected to eat at least a few hundred calories a day more than small women (you know, 2800 a day instead of 2400, or whatever) - NOT the opposite.

Anonymous said...

With my first pregnancy, my doctor made me feel so ashamed that I'd gained weight so fast in my first trimester. By the end of my pregnancy, I'd gained 30 pounds, totally normal, but it was double what I was "supposed" to gain.

Now that I'm pregnant again, (and haven't lost any of the old baby weight) I feel very self-conscious and I feel nervous about seeing my doctor. Nobody should feel this way and the fat shaming has to stop.

Anonymous said...

I felt exactly the same with my last pregnancy. It was a horrible feeling. . They treated me like I was this big fat unhealthy pregnant woman scarfing down double cheeseburgers everyday. . I gained 50lbs but dropped 35lbs after 2 weeks of giving birth. . Some woman like myself tend to retain alot of water. .

Anonymous said...

With my first pregnancy, I had an eating disorder. Once I discovered I was pregnant at 19 weeks, I turned my life around and started eating. I gained 65 lbs by 30 weeks. Although I started out underweight, my doctor literally went as far as being verbally abusive about my weight gain. Now, on my next two pregnancies (currently pregnant) I battle anorexia. This is why I do not agree with dieting during pregnancy. The mind is so fragile, it can cause so much damage to the mother, as well as the baby, to follow their advice to a T. Please, do what YOU think is right. Be happy. Don't bully yourself and if your doctor wants to rip you apart, please find a new doctor.

Emotional mess said...

A long time ago I used to cut. Im very self concious about my weight amongst other things. My doctor shredded me for gaining 3kg over the recommended weight gain for my bmi at the start of pregnancy and how bad it could be for me... How awful it was for baby. It destroyed me. Sliced my arm up at home alone after that checkup and have now spent the past few weeks hiding it while it heals coz Im too ashamed to admit i fell onto what was for me... a stupid teen habit. Some doctors are cruel and even if they are 'just doing their job' there are far kinder ways to deal with volatile / emotional pregnant women, especially on whats generally a touchy subject, pregnant or not.