Thursday, September 23, 2010

Prenatal Weight Gain: When the Conclusion is Made Ahead of the Results

Several people wrote me last year to send me the link to the New York Times article, "New Goal for the Obese: Zero Gain in Pregnancy."

Believe me, I'd already seen this article and others similar to it. There are SO many things to object to object to or comment on, it was hard to know where to start and I've been spinning my wheels for a long time, trying to find a way to communicate my concerns effectively without a giant rambling reply. 

But darn it, this sort of thing needs to be challenged, and currently very few people in the media, the fatosphere, or the birth world are even questioning strict limits on pregnancy weight gain in "obese" women. 

So I'm going to ramble away, because this sort of thing must be challenged.  Here are a few of my concerns with this specific study and so many of the others like it.

Publicizing the Outcome Before The Study Even Begins

I think the thing that bothers me most in this Kaiser study is that the results are a foregone conclusion.

It floors me that these researchers published an article ---in the New York Times, no less---essentially promoting a conclusion they hadn't even studied yet.

It's not like these researchers had already done the study and concluded from data that gaining no weight in pregnancy was best for obese women.

No no no!! They were just starting the why were they already publicizing their conclusions?

The problem is that these doctors have already made up their minds that little or no weight gain leads to the healthiest outcomes in obese mothers, and that this was the message that needed to be pushed to consumers and other doctors.

It's marketing this message that is their main concern. Why else would they be publicizing their uncompleted research like this?

There is an army of OBs out there who have reverted to the old teachings about the "dangers" of too much weight gain in pregnancy and have a TREMENDOUS agenda to promote extreme restriction of weight gain (or even weight loss) in "obese" women in pregnancy.

These OBs have been aggressively marketing the idea to the press that fat women gain "too much weight" in pregnancy and that restricting such weight gain can improve outcomes. Over and over, we have seen them pushing this agenda with the press.  This is just the latest salvo in their campaign.

The phrasing of the NYT article (just look at the title...."New Goal for the Obese: Zero Weight Gain in Pregnancy") also bothers me because many people will scan the article and conclude that the study has already been done and that gaining no weight in pregnancy is best.

In fact, all the article is doing is telling people that they were starting a study to see whether gaining no weight improves outcomes......but many people (including many doctors) probably read the story and believed that gaining no weight is now the standard of care.

These researchers are trying to create an expectation in the public and among birth attendants that this no-gain policy is the new standard of care for obese women, that any gain must be prevented for women of size....and perhaps even that weight loss during pregnancy is the most optimal course of all.

This is what I'm hearing from women of size now....that they are being told to gain little to no weight in pregnancy, and many more are now even being told to lose weight during pregnancy.

In fact, THIS IS NOT THE STANDARD OF CARE AT ALL, nor should it be.  There are significant reasons for concern with a policy like this.

Prenatal Weight Gain Politics

The IOM (Institute of Medicine) came out with revised guidelines earlier this year, recommending a new pregnancy gain of 11-20 pounds in obese women.

This is down from a previous recommendation for obese women to gain "at least 15 pounds" (often misreported as "no more than 15 pounds"), but the news wasn't all bad.

The good news was that the IOM resisted pressure to lower the guidelines to NO gain (or even weight loss) for "morbidly obese" women, saying there was not enough evidence in that group to make a decision.

The bad news is that now we are going to see a plethora of studies, intervening and trying to keep "morbidly obese" women from gaining any weight in pregnancy....and no doubt coming to their conclusions ahead of time, just like this study.

My concern is that the studies we will see on this topic will not be fair, rigorous, or powerful enough to really make any decisions about the best course of action.....but that it won't matter, because The Powers That Be have already made up their minds about what's best, and will use bad science to try and push their agenda as part of their "war on obesity." 

And I'm afraid of what the price will be for women of size and their babies.

Details on the Study

Here are more details about the study from the Kaiser press release on October 21, 2009.
Kaiser Permanente is launching the first clinical trial to help obese women control their weight during pregnancy. The “Healthy Moms” study, funded by a $2.2 million grant from the National Institute of Child Health and Human Development, will begin recruiting this month.

“The goal of the study is to keep obese pregnant women from gaining weight. We believe they can safely maintain their pre-pregnancy weight and deliver healthier babies,” says Kim Vesco, MD, MPH, a practicing OB/GYN and researcher at the Kaiser Permanente Center for Health Research, who will direct the study.

This is the first study to test a weight maintenance program for obese pregnant women, and the first to use weekly support groups as part of the intervention. A small study in Denmark did limit excess weight gain in obese pregnant women, but they still gained an average of 14.5 pounds. Two other larger studies failed to prevent excessive weight gain in obese and overweight pregnant women.

“It may seem counterintuitive to suggest that women control their weight during pregnancy, but these women are already carrying between 50 and 100 extra pounds — and for them any more weight gain could be very dangerous,” said Vic Stevens, PhD, principal investigator who has studied weight loss and weight maintenance for more than 30 years...

The “Healthy Moms” trial will enroll 180 obese pregnant women from Washington and Oregon who are members of the Kaiser Permanente health plan: half will receive one-time dietary and exercise advice; the other half will attend two individual counseling sessions and then weekly group counseling for the remainder of their pregnancy. Women who attend the sessions will be weighed and encouraged to keep and turn in daily food and exercise diaries. Professional weight counselors will facilitate the groups and help motivate the women with behavior change techniques.

The study will follow women throughout their pregnancies to find out how much weight they gain, how large their babies are, and how much weight they retain one year after they give birth. It will also look at birthing complications, the baby’s growth and feeding practices, and whether the mother continues with dietary changes after the baby is born. The study will recruit women for 18 months, and preliminary results are expected in three years.
Thoughts on the Kaiser Study

First off, I should note that I don't object to everything in the study, contrary to what many of the Obesity Mafia would expect.

I think it's very important for women to exercise in pregnancy, and I agree it's good to discourage consumption of things like sweetened drinks and junk food. I don't have a problem with recommending those, and I have no doubt that these interventions probably will be associated with lower risks of some complications in pregnancy.

Nor do I think that obese women gaining little weight is automatically dangerous. I personally had a net gain of about 5 pounds in my pregnancies (lost 10 lbs., then gained back 15)...not because I was trying to limit my gain, was eating "better" than usual, or because I had a lot of nausea, but simply because pregnancy revs up my metabolism in a major way.

I know from personal experience that you can have a perfectly healthy pregnancy with a very small gain. Some fat women do gain very little in pregnancy, not because they have "healthier" nutrition than those who do gain, but simply because pregnancy changes their metabolism more.

My concern is promoting no weight gain as a goal for ALL obese women, and using potentially draconian means to get it.  Many women can't achieve null weight gain without drastically limiting calories and thereby nutrients. In what way is that healthy? 

The research (in other weight-limitation studies) shows that many "obese" women have difficulty meeting weight gain limits of 15 lbs. already.  Not because they are pigs and can't lay off the french fries and bon-bons, but simply because most pregnant women, including fat women, gain at least the weight of the baby, placenta, and extra fluids in pregnancy

In addition, many women of size who are chronic dieters or who have lost weight before pregnancy gain more during pregnancy because their bodies compensate physiologically to have enough energy for birth and breastfeeding.  The body thinks it's starving, so it becomes more efficient and stores up more fat for reserves, even with normal eating.

So is it really realistic and fair to make fat women gain NO weight in pregnancy and to make them feel guilty if they do gain weight, despite eating well?  I don't think it is. I think it sets them up for failure, for feeling guilty, and for disordered eating.

I think it puts the goal on the surrogate target of weight gain, when it really ought to be putting the target on the real goal...healthy nutrition, healthy baby, and healthy mommy.

If Only....

Wouldn't it be nice if this study had a Health At Every Size (HAES) component to it? If they had a group where increased exercise and reasonable eating guidelines were promoted, yet the emphasis was simply on really excellent nutrition and exercise, regardless of actual gain

Wouldn't it be nice if there were a group where women weren't made to feel like failures if they gained pregnancy weight despite doing everything "right"? 

And wouldn't it be great if they compared long-term maternal and fetal outcomes, long-term healthy eating practices, and long-term weight outcomes from each program to see which had the best results? 

I have a hunch the results would be similar to the U.C. Davis HAES study, which found that emphasizing healthy habits along with body acceptance resulted in better long-term health outcomes than emphasizing weight loss. 

I know, I's a pipe dream.  When doctors are convinced that strictly limiting weight gain is the "magic bullet" to preventing complications in the pregnancies of women of size and preventing obesity in their offspring, it's too much to hope for that they could mentally uncouple healthful habits from restricted gain.  They simply cannot separate one goal from the other; in their minds, the two are always connected. 

But very low weight gains are already difficult for many women to achieve; lowering the bar to even more restrictive gain is not going to be any more effective or achievable.  Furthermore, weight gain is a poor surrogate for fetal outcome in most cases, so making that the focus does little to promote fetal health.

Perhaps what they should be doing instead is emphasizing healthy habits and long-term outcomes...healthy nutrition, healthy baby, and healthy mommy...over actual numbers on a scale.

Next up:  Study Design Issues and Long-Term Safety Concerns in these "restrictive weight gain" studies.


Evenspor said...

This really bothers me. Limiting weight gain for women of any size during pregnancy bothers me (as opposed to just promoting healthy lifestyles as you mentioned). Every woman I know has a body that reacts differently to pregnancy. I know a family where every woman has gained around 60 pounds during pregnancy, but it all comes off later. I've known women who gain hardly anything during pregnancy, but they can't lose any weight while breastfeeding. I think for the most part, our bodies know what we need. The possibility, though, of not getting the mama or baby enough nutrition just because it satisfies some randomly picked weight number that worked for someone else... scary.

I am so glad that so far all of the OBs have had have not made a big deal about weight gain.

JeninCanada said...

I've never understood how anyone could possibly gain no weight or even lose weight during pregnancy. Between the placenta, fluids, fetus, increased blood supply in the mother, breast enlargement of some degree, you're going to put on some pounds! I gained 40lbs with my son and lost 30lbs over the course of several months afterwards and a lot of that immediately thanks to not being pregnant. Evenspor is right; every body during every pregnancy is different and every body knows what it needs for itself and the fetus.

Cassandra said...

I dropped 15 lbs within my first two months of pregnancy. As of 36 weeks, my weight was still about 5 lbs below pre-pregnancy weight. Similar to WRM I think my metabolism went into overdrive, plus I had absolutely no appetite most of the time. It was a struggle to eat.

When I agreed to do a food journal for a month to be reviewed by my midwives, I was encouraged to eat more calories and they thought I was getting dangerously low when some days I was only eating about 1500. Also, that brings up a question - one student midwife said the goal for caloric intake during pregnancy is 3000, but then my husband's cousin who is a student midwife also said "30-100 calories more than before and if you already have reserves you shouldn't make any change", which one is right and where does this crap come from? The cousin felt a need to speak out when I commented about being amused by the midwives telling me, the big fat cow, to eat MORE. In the end my only real thought was: How about I eat whatever the hell my body, and baby, says I should be eating?

Hazelnut said...

I think the fluid volume is often underestimated. I never had blood pressure or urine protein issues during pregnancy, but I lost 20 pounds between my last prenatal appointment and my incision check 6 days after surgical delivery, and my ankles were still swollen at that point -- I was down another ten pounds at the post-partum appointment five weeks later. Thirty pounds in nine months wouldn't be an unreasonable rate of weight loss, I suppose, but it seems like a lot to lose during pregnancy.

Katie said...

My insurance is through Kaiser, and I've seen posters for this sort of thing in the clinic throughout my pregnancy. It angers me. I am not overweight - in fact, I'm more likely to be underweight for my height and build - but this sort of thing makes me scared that some idiot's going to look at the raw numbers of my weight and not *me* and start pushing weight loss. This actually happened during my first pregnancy; I had *finally* gained a substantial amount of weight which I needed badly, and the midwife I saw that day (who'd never seen me before or since) looked at the twelve pounds I'd gained in four weeks, didn't have the least clue that it was a hard-won triumph for me, and told me to cut the carbs. As it happens, I gained very little weight after that (not because I deliberately cut any calories) and gave birth easily to a 7lb 1oz baby. I am making an effort with this pregnancy to keep my care with the same midwife the whole time, to avoid any such idiotic remarks, but you can see how angry I still am about it two and a half years later!

I started this pregnancy at an "underweight" BMI, and have gained around 20 pounds from the lightest I got to (about 15 from starting weight), but I'm still paranoid that someone's going to tell me that I've gained too much, just looking at numbers. I'm still too thin, it's all baby weight! I can only imagine how awful it would be if I had actually started out "overweight".

Tanz said...

I had twins 4 months ago and my midwife advised me not to put any weight on during my pregnancy. I was shocked - I mean, how can any supposed educated person think it's healthy for a woman carrying twins to *lose* weight (because I'd have to do that in order to keep those scale measurements steady). Even more shocking was that during my last twin pregnancy 5 years ago my weight was never mentioned, even though it was about the same (approx. 130 kilos pre-pregnancy each time).

Even worse when I post about this on parenting forums I'm told that of course being fat will harm my baby and make my pregnancy harder, and that if I had any sense I would have followed my midwife's suggestion. When I respond that things were fine for me - both sets reached 38 and 37 weeks gestation respectively, with all 4 being 7 pound babies) they refuse to believe me. Sure, my experiences aren't proof of anything - but then neither are assumptions that we fat women are going to explode if we go over an arbitary number in pregnancy.

Oh, and this second time around I gained almost 20 kilos, all of which evaporated by itself afterwards; I was back in my pre-pregnancy jeans by week 2. Weight is unpredictable in pregnancy. Health is what matters; eating well and getting both exercise and rest.

sara said...

I am 5'3" and have always been "heavy" for my height since I carry weight in my legs. When I got pregnant I was 150 pounds despite intense cardio workouts several times a week, a healthy diet, weightlifting, etc. Obviously I wouldn't be in the obese category, but definitely overweight.
During my pregnancy I gained 30 pounds even though I didn't pop much at all- my next door neighbor never knew that I was pregnant! Also, I exercised throught my pregnancy- 4 days a week of step, weights, and swimming. Yet I STILL gained 30 pounds! If I gained that much with all of that effort I do have sympathy for women who aren't able to be so active during their pregnancy- it would be very difficult to not gain any weight. 10 days postpartum I had lost 22 pounds, and 6 months later I was down to 135, less than I had been since I was a teenager. I agree that the emphasis really needs to be on promoting good habits during pregnancy that will stick with the women afterwards- and if breastfeeding is encouraged many of those women may find that they lose the weight very quickly and continue to lose it as I have!

Tami said...

Each of my pregnancies has been different, from gaining 50 lbs to losing 20 lbs during the pregnancy (net change). The amount I gained/lost had nothing to do with the health or weight of the baby, or my own health either. It's just what my body did. Now I'm 23 weeks along with #5, looking at a net gain of 8 lbs at this point. The focus needs to be on eating healthy foods, not on weight gain or loss.

Anonymous said...

I'm pregnant with my first and my first OB appointment could not have gone worse. I was told I was too fat to have the baby in the hospital. WTF? The doctor advised me that if I didn't want to drive 2.5-3 hours to another specialty hospital that I better lose weight. I need to lose about 30 pounds before the hospital 5 mins down the road will take me. Apparently they force ladies in labor to stand on a scale so they can determine BMI. If your BMI is over 30, then you're too fat to give birth in the hospital. I suppose they think it's safer for my husband to deliver the baby on the side of the road. So far, I have no complications, apparently being overweight is worse than GD, Preclampsia, etc. It's turned a joyous time into an absolutely depressing nightmare. I remember being so excited when I got the positive, I never knew the hospital would say sorry, it's not safe to have your baby here, go have it on the street or at home instead. My mom has told me that I should wait until the head is crowning, then go in and watch them try to weigh my big butt. LOL. I don't think so! But anyway, I'm still trying to get over the idea that this is out of my hands. I'm doing all I can with exercise and weight loss, hopefully it'll be enough.

Anonymous said...

At my first visit, my OB told me to gain no more than 10 lbs because of all the health risks involved with being obese and pregnant (I started off 260/5'7). So, I gave a valiant effort to do so, terrified of being a 'statistic'.
Well, here I am at 29 weeks, having gained a whopping *28 lbs* thus far, and I really feel like smacking someone. Not only do I have PERFECT glucose levels, constant PERFECT blood pressure, PERFECT Hemoglobin levels (I'm not kidding you, I am literally textbook), I also have severe ANXIETY; I still worry that something will go terribly wrong, *even with medical proof that my pregnancy is great*, because of my weight. Correct me if I'm wrong, but isn't anxiety/stress just as bad for a pregnant woman, yet doctors don't really seem to mention in those studies how their bias can effect patients emotionally. Interesting.

Night said...

Annonymous #1, You are being lied to. If you show up at the hospital in labour, they CAN NOT refuse to treat you, to do so is to open themselves up to a massive law suit.

Run, run away as fast you can from this OB. Maybe you can find a nice birthing centre or homebirth midwife?