Sunday, October 31, 2010

Happy Halloween

Happy Halloween to all who celebrate it!
I know my kids have all been anxiously awaiting October 31st; my little one has been impatiently counting down the days.  She's so excited to realize the day is finally here!

One thing I've done over the years was to keep a journal of some of the cute things my kids have said or done.  They really enjoy going back and hearing some of the silly/funny things that came out of their mouths when they were little. 

In the back of this book, I've kept a list of who dressed up in what costume each Halloween over the years.  We got it out the other day and they had a lot of fun remembering their various costumes.  I highly recommend keeping a list like this.  You'll love it someday and so will they.

If you were really ambitious, you might even keep a special photo album devoted only to various Halloweens over the years.  It would be a really lovely documentation of how each child grew and changed, all in one little album. 

My favorite years have been the years we had themes going.  One year the big three kids all did Star Wars costumes, along with some other friends.  My older daughter as Princess Leia (complete with Cinnamon Bun Hair) was hysterical. 

The sweetest years were the years of the Peter Pan theme.  One year, when the eldest two were preschooler/toddler, my daughter was Captain Hook and my son was the Crocodile. That was cute.  Another year, after all four kids had arrived, the boys dressed up as Peter Pan and Captain Hook, and the two girls were Tinkerbells (they both wanted the fairy wings).

I love themed years....but most years the kids just aren't amenable to that. This year, I have an age range from teenager down to little. That makes for an interesting range of costume choices...and makes a theme highly unlikely anymore.  That makes me a little sad, but c'est la vie.  Their interests are just too far apart now.

The oldest teenage girl is going to dress up "Goth" for Halloween and go over to a friend's house.  She is looking forward to being able to temporarily dye her hair (it washes out) and wear Goth make-up.  She also has those sleeves that make you look like you have tattoos, and temporary press-on long nails.  I have parent friends who are horrified that I'm letting her dye her hair and go Goth, but I figure, better to let her try rebellion on in a temporary form, right?  I think part of what teens do is "try on" different possibilities; doing this for Halloween seems pretty harmless to me.  It's only one night; why not let them be outrageous one day of the year?

My teenage boy is doing what teenage boys do.....going spooky.  He's got an all-black cape/robe, black gloves etc., and a silver skull mask with black headpiece.  Since he's getting pretty tall now, he really does look pretty creepy in it.  I'm taking him to be a performer in a haunted house during the day, and then he'll come home and enjoy his last year of trick-or-treating.  Honestly, I think his is the best costume this year.  Verrrrrrry creepy.....and he'll milk every second for all it's worth.

My little boy is going Ninja this year.  I found a great black robe at Goodwill, and some Ninja acoutrements from the local  MegaMart.  He thinks he is very cool indeed.  I think he looks adorable, trying to be all tough and cool when he is so clearly still a very sweet little boy.  Gotta enjoy it while it lasts!  All too soon he'll be in the looking-creepy phase too.

I had a lot of angst over my little one's costume this year.  She has been a Princess each year since forever.  She is the girliest-girl you have ever met, which is a mystery to my older daughter and me because neither of us are girly-girly at all.  But this is just the way she came, and she's been like that from the start (with no encouragement from us), so we just let it be.

So Princesses it was for her, every single year she was old enough to choose (except the year we talked her into Tinkerbell by telling her that Tink was a fairy princess). 

Last year her princesses began to alter a bit and she went as a Cowboy Princess.  Full princess regalia but with a cowboy hat etc.  It was very cute.

This year, she spent too much time listening to my teen daughter and her friends who HATE pink and who idolize black instead.  So now she tells me she doesn't like pink anymore and doesn't want to be a princess anymore.  Sob!

I thought I'd be thrilled to have her past the ultra-girly Princess phase, but actually I'm quite sad to see it passing.  (Not to mention ticked off at the teenagers who pressured her out of this phase before she was really past it.)  It really was so very precious and sweet, so much a part of her own natural personality, and I wanted her to stay in that magical little-girl pretend phase for as long as possible. 

She started out wanting to be a Princess again for Halloween this year.  Without teenage influence, I'm convinced she would have stayed one.  But then, as her brother and cousin decided to be ninjas this year, she decided she'd be a Ninja Princess for Halloween.

Fine, I thought that was a pretty funny combination....it let her still do the Little-Girl Thing but yet added some Kick-Butt Defend-Yourself vibes in there.  I'm all for that.

But when her siblings heard she was going to be princessy yet another year, there was much moaning and groaning.....and so my sweet little girl decided she couldn't do the Princess Thing again.  My heart broke, and I could have killed the siblings for ruining what would have been a classic Halloween costume we could have laughed over later.  I mean, Ninja Princess....how perfect is that?

So then she was going to be just a Ninja.  That was okay, but so unoriginal.  She'd be just exactly what her older brother and cousin were going to be.  Boring.  Themes are great, but not if each child is a carbon copy of the other. Bleah.

Ah, but then inspiration struck while we were at our local MegaMart.  I brought her home an awesome pair of black fairy wings and let her play with them for a while.  She was totally enchanted by them.

So now she has decided that she wants to be a Ninja Fairy for Halloween this year.  You should see her, all decked out in her black outfit, her Ninja robe, and then her fairy wings on top of it all.  So very precious....so funny and so sweet.

So while not quite a full-on Princess this year, she still managed to preserve some of her Little Girl Mojo and keep the fanciful pretend phase a little while longer. 

I'm so thankful.  I think the imaginative play phase is such an important part of a child's development, and so sweet for the parents too.  I'm glad my little girl will stay little just a while longer.

What are your kids going to be for Halloween this year?

*Image from Wikimedia Commons.

Tuesday, October 26, 2010

Too Out Of Shape For Birth?

Here's another little gem from the blog, My OB Said What?.  It covers the common misperception among obstetric caregivers that fat women are too "out of shape" to give birth vaginally and/or naturally. 
“You are quite overweight and you need to be healthy to naturally birth a baby. You wouldn’t make it because you would get puffed out and tired.”
-OB to overweight mom who wanted a natural birth
This is a very common belief among many people, both lay and medical.  The idea is that you have to be in great athletic shape in order to give birth naturally. 

There are two problems with this. 

First is the common assumption that "overweight" and "obese" women never get any exercise and therefore this mother couldn't possibly be in decent shape. (The corollary, of course, is that all average-sized women obviously do get exercise and are always more fit than fat folk.)  Neither is true.

Second is the assumption that you have to be fit in order to give birth naturally, that labor and birth is like running a marathon and only the most fit and tough can do it naturally.  Baloney.  Fitness helps, but it's no guarantee either way.

Assumption: "Obese" Women Never Exercise And Aren't In Shape

Many doctors and laypeople assume that fat people never exercise and can't possibly be in decent shape.

This is nonsense.  Many fat women do exercise and of course, many skinny ones do not.  You can't tell by looking at body size who gets exercise and who does not. 

It goes back to that common societal belief that if you are fat, it must be because you don't eat well and don't exercise at all.  Anyone who made any real effort at it would obviously be "normal-sized" or pretty darn close to it.  Therefore, in that mode of thinking, all fat people are, by definition, not fit.

I would agree that it's possible that fat people, on average, may be less fit than average-sized people....certainly fatness can be more physically challenging in some ways (especially as we age), there are many barriers to exercise for people of size, and some fat people really are sedentary....but you just cannot make assumptions about individuals based on size.  I know "overweight" and "obese" people who run, bike, and hike regularly and are very fit.  I also know ones who are not.  But you can't really tell by looking.

This doctor should not be making assumptions about fitness level based simply on the mother's size.

Assumption: Only The Most Fit Can Birth Naturally

Although I think it's true that it helps to be reasonably fit for pregnancy and birth, it's certainly not a requirement for normal vaginal birth.  The uterus is a muscle and works independently of the fitness of the rest of the person. 

I mean, for heaven's sake, there have been cases on record where paralyzed women have given birth vaginally.  If a person who cannot actively help push out her baby can birth vaginally, then obviously fitness is not an absolute pre-requisite for giving birth vaginally. The uterus can do it on its own, if the baby is well-positioned.

That said, pregnancy is wearing on the body and labor is certainly not a walk in the park.  I do think that folks who get regular exercise in pregnancy tend to have fewer complications in pregnancy (less gestational diabetes and perhaps less pre-eclampsia), and it may help them have an easier birth.  It also helps to have some endurance on board if the labor is hard or long. 

However, fitness and athleticism are not an absolute requirement for having a vaginal birth or a med-free childbirth.  I know plenty of very fit, very athletic women who have had cesareans, and plenty of not-very-fit women who have had vaginal births (and natural, unmedicated vaginal births at that). 

My Experience

In my own life, I exercised quite a bit in pregnancies #2 and #3, but because of coincidental life issues, not as much with #1 and #4.  (I was "morbidly obese" and of similar weight with each, so that was not a relevant variable on its own.)

I had very little exercise and a cesarean with the first, exercised a lot with #2 but still had a cesarean, exercised a lot with #3 but had a vaginal birth, and exercised not-a-lot with #4 and still had a vaginal birth (a completely natural, unmedicated birth in the water to boot). 

I did notice a difference in how I tolerated pregnancy; I definitely was most comfortable in the pregnancies in which I exercised regularly.  So I'm a big fan of promoting exercise for pregnant women of all sizes.  But not getting as much exercise in my last pregnancy didn't prevent me from having a vaginal birth. 

I absolutely encourage women (and especially women of size) to exercise regularly in pregnancy because it really does help you feel better, lowers your risk for complications, may help you during labor, and will help your body recover faster afterwards.

But do you have to be skinny or an athlete to have a vaginal birth?  Of course not.  Just read the comments on the My OB Said What? page.  Many were from fat women who birthed vaginally and all naturally just fine, with or without regular exercise.  And I have birth stories on my website from fat women, even supersized women, who have had natural vaginal births without problems.

Yes, fat women have more cesareans.  But is that really only because of their fatness, or because of a combination of more complications, an extremely high rate of induction in fat women, the extremely interventive way that fat women's labors are managed, a higher rate of malpositions, and a very low threshold for surgery for fat patients among their OBs?

Conclusion

Focusing on fitness/exercise as a requirement for natural birth is just another argument that doctors (and sometimes midwives, alas) use to convince fat women that they:
  • will "need" a cesarean
  • couldn't possibly push out a baby because they are too unfit or too fat
  • couldn't possibly push out a baby without help from forceps or vacuum extractor because they aren't strong enough to push hard enough
  • are too weak to endure labor without drugs
  • won't produce strong-enough contractions on their own and will definitely "need" pitocin
  • couldn't possibly have a vaginal birth without losing tons of weight or taking up marathons beforehand
(Yeah, those are all real things that have been told to women of size.)

Let's be clear. Fat women can and often do exercise.  Just because you are fat doesn't mean you don't exercise.  Could many fat women exercise more?  You betcha.  Could many average-sized women exercise more?  Yes. You simply cannot make assumptions about exercise habits and fitness based on a person's size.

Second, exercise and fitness is NOT necessarily a pre-requisite for birthing vaginally.  It definitely helps, and women should definitely be encouraged to be active in pregnancy....but the story is much more complex than that.  There are far more factors than fitness and athleticism at work in birth.

So is fitness an absolute requirement for birthing vaginally or without medications? Heck no.

And can fat women, fit or unfit, birth vaginally? Hell yes.

Tuesday, October 19, 2010

Gaining weight in pregnancy means a cesarean?

A very telling question was recently asked on the Lamaze Forums, one that seems like a perfect footnote to the discussion we've been having about extreme weight gain restriction in women of size in pregnancy:
I have a friend who is finally pregnant after 5 years of infertility. She went to her doctor's appt today and was told that if she gained anymore weight she would need a c-section. She admits that she is overweight, but has been vigilant in her diet and is exercising daily, unfortunately she can't seem to keep the weight off. Is there any reason that being overweight would automatically equal c-section?
Henci Goer moderates the questions on these forums.  Here is her reply:

No, but her doctor's statement is a good reason to find another care provider ASAP. Her doctor's belief in her inability to birth vaginally is extremely likely to become a self-fulfilling prophecy. The research is rock solid that cesarean rates depend far more on the individual care provider's judgment and practices than on factors that have to do with the woman.
Amen to that.  Let's say it again:

Cesarean rates depend far more on the individual care provider's judgment and practices than on factors that have to do with the woman.
 
In this case, the care provider believes that a fat woman should have an automatic cesarean if she gains "too much weight" in pregnancy, no matter how healthfully the weight is gained.

This belief that fat women "need" a c-section because they either "cannot" birth vaginally or because it is "far too dangerous to allow them to try if they gain too much weight" is another reason the cesarean rate in women of size is so high. 

This is reflected by a comment left by another midwife who has since learned differently:
I was an OB nurse for 10 years prior to becoming a midwife.  There is a strong bias against overweight women on the OB floor.  We always talked about how long we'd have to wait before the decision was made to have a c-section.  We truly believed an overweight woman's body truly couldn't accomplish a natural birth. 
This is the kind of attitude that we, as women of size, are up against. Most of the care providers don't believe we CAN birth vaginally, or that we even SHOULD. Many believe that it is far too risky to "allow" us to even try and it's better to just schedule that c-section in advance to "save" the baby from our toxic bodies.  Or to schedule that induction early before that baby gets "too big" from all our out-of-control eating, don'tyaknow.

And now the trend is that women of size who gain "too much weight" in pregnancy (which might mean very little in comparison with other women) should be scheduled for a cesarean. 

This is one of the major problems with the push to restrict weight gain in women of size; those who gain "too much" weight may be punished for it, consciously or unconsciously.  They are assumed to have grown very big babies, and so are scheduled for either early induction or planned cesarean as a result, despite strong research showing that these practices actually increase harm.

The push to restrict weight gain in women of size, while ostensibly to prevent more cesareans, may actually result in many "obese" women having cesareans who may not have needed it, simply because they gained "too much weight" for their doctor's comfort level.  (And "too much" may mean anything from gaining more than 15 lbs. to gaining ANY weight at all or failing to LOSE weight, which is what many doctors are pushing for now.)

It's the perfect Catch-22.  Set the weight gain limits so low that very few fat women will be able to meet them, even when nutrition and exercise habits are great.  Make those who don't meet the goals have planned cesareans or early inductions because otherwise, "it's too dangerous." 

Fewer pesky and inconvenient labors to attend, a schedule that's easier to work around your office hours, plenty of convenient and quick cesareans to do, and plenty of money for the NICU for all those babies who then experience breathing problems, fetal distress, low blood sugar, or jaundice.

The perfect score for hospitals everywhere.

I'm not so conspiracy-minded as to think that most hospitals and doctors consciously think this way because they are "out to get" fat women.  I think most truly believe they are doing the babies of women of size a favor by scheduling them for cesareans or inductions to "save" them from the "dangers" of natural vaginal birth in obese women. 

But are they really better off?  I don't think so.  Babies of cesareans often have significant issues getting started, and end up in intensive care more often than babies born vaginally. And the women themselves are certainly not better off after a c-section, and especially women of size, in whom surgery is inherently more risky.

This push for extremly restricted gain in women of size has many scary implications, and one of them is the punishment for fat women who gain "too much." 

Apparently, they really believe that everyone can keep from gaining "too much" if women are dedicated enough and work hard enough, and that gaining "too much" must be because women are eating excessively and being a couch potato.  But there are far more factors at work here, and I'm not convinced how much prenatal weight gain is 100% under our control.  Some yes, but not all.  There are too many other variables.

I don't have a problem with programs that focus on excellent nutrition and increased exercise, as long as goals are reasonable and the protocols are sensible, not restrictive.  Granted, I think everyone could benefit from such programs and dislike seeing them target only fat women, but reasonable programs humanely done are not my big worry.

I do have problems with programs that are highly restrictive in nature, use emotional manipulation and scare tactics to try and scare fat women "straight," press extreme weight gain restriction agendas, make women feel guilty and neurotic about their weight gains, and which punish women who exceed the "recommended" gain.

THAT I definitely have a problem with.

Friday, October 15, 2010

National Pregnancy and Infant Loss Remembrance Day

There is no foot so small
It cannot leave an imprint
On this world


Today we remember all babies born sleeping, or whom we have carried but never met, or those we have held but could not take home, or the ones that came home but didn't stay.

Today, October 15, is national infant and pregnancy loss remembrance day.

If you or someone you know has lost a baby during pregnancy or infancy, light a candle in remembrance of this tiny life. This wave of light begins 7 p.m. in all times zones around the world.

http://www.october15th.com/

*In memory of William George, born still April 1, 2009; beloved son of a dear online friend.

And in memory of all the other babies I have known who were born still.  I remember you and hold your families in my heart.

Tuesday, October 12, 2010

Prenatal Weight Gain: The Importance Of Study Design

We've been discussing prenatal weight gain politics for "obese" women again.  This is part of a continuing series we're doing on nutrition and weight gain in women of size during pregnancy.

To recap briefly -- how much weight fat women should gain during pregnancy is a very hot topic in obstetrics these days. A number of studies on restricted gain have come out in the last several years, and there are certain to be many more in the future. In addition, the Institute of Medicine released newly revised guidelines for weight gain earlier this year, changing the recommended gain for "obese" women from "at least 15 lbs." to "11-20 lbs." (a slightly lower recommendation than before, but not as low as critics wanted).

The hope among those who promote restricted gain is that the risks of pregnancy in "obese" women might be reduced or eliminated by restricting weight gain, and that this might also prevent obesity from getting worse in the long run for the mother, and perhaps prevent or lessen it for the child.

Earlier in our series, I wrote about a Kaiser study started last year (and publicized in the New York Times) about promoting ZERO weight gain in pregnancy for fat women.  Then we discussed the research showing harms already associated with little gain in pregnancy in "obese" women, and what harms might result if the weight gain recommendations are reduced even further. 

Today we talk about study design limitations in weight gain restriction research, and how the design of most studies does not allow them to conclude that restricting gain is "safe." 
Let's take a critical look at the research on this topic.

The Kaiser Study

Just in case you missed earlier posts on it, I'll repeat some of the 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 goal of the {"Healthy Moms"] 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.
Remember, the researchers publicized this study before they had even done the research.  This is not objective research; this is Science By Press Release, designed to push a pre-set agenda.

The title of the NY Times article was "New Goal for the Obese: Zero Gain in Pregnancy." Although the article briefly discusses the controversy over whether gaining no weight is safe, many people will come away from the article with the conclusion that no weight gain is the standard of care and the best goal for "obese" women during pregnancy.  This is pure public relations marketing in order to push a public health agenda that has actually not yet been proven to be safe or effective.

This is only the first in a plethora of studies to come on little or no weight gain in pregnancy, as bariatrics obstetrics specialists push their agenda of strictly enforced weight gain in fat women.  But can studies like this one really conclusively decide the safety and effectiveness of such an approach?

Concerns About the Study Design

I have a number of concerns about the study design of this study (and of all of these "limited gain" studies).  Let me summarize the main ones.

Sample Size Issues

One major concern is whether the studies will be large enough to detect the influence of low gain on relatively rare outcomes like stillbirth.

Most of these studies on restricting weight gain either do not report on low gain's effect on stillbirth, or the studies are so small that they are not powerful enough to detect a difference in such rare events as stillbirth. 

However, some large studies not specifically on restricting weight gain have found an association between low weight gain and stillbirth even in "overweight" and "obese" women, but rarely are these mentioned in the studies promoting restricted gain. 

This Kaiser study will have 180 women in it. Only half (90) will be in the arm that intervenes to prevent weight gain. Can a study group of less than 100 accurately show that stillbirth rates (usually a few per thousand) are not affected by restricting weight gain?

Yet I have no doubt that the researchers will conclude at the end that restricting weight gain is "perfectly safe" and has no untoward negative effects. The problem is, they will not have investigated that at all.  Their study does not even begin to have the power to determine whether such an approach is "safe."

And frankly, a study arm of less than 100 is not enough to determine much of anything for certain, let alone to push a policy change with potentially far-reaching consequences.

Causation Versus Correlation

Another problem seen constantly in these weight gain prevention studies is confusing causation with correlation.  This is particularly prevalent when trying to tie together weight gain and pre-eclampsia. 

A number of studies (like the Missouri study and the Cedergren study mentioned above) have found that obese women with lower weight gains have lower rates of pre-eclampsia. Therefore, they imply that if we can prevent fat women from gaining much weight, we can lower their risk for pre-eclampsia (PE).

The problem is that fluid retention is one of the symptoms of pre-eclampsia; it does not mean that restricting weight gain prevents pre-eclampsia. 

Just because there is an association between two things does not mean there is a causal relationship.  Because increased weight gain is a side-effect of developing pre-eclampsia, it is hard to distinguish whether or not a higher relative gain causes PE or is merely a by-product.

In other words, women with lower gains have less pre-eclampsia, but that doesn't mean that deliberately restricting weight gain will prevent pre-eclampsia.

These studies should note that there is an association between low weight gain and less pre-eclampsia, but not necessarily a causal connection. Yet many of these weight gain studies strongly imply that if we keep fat women from gaining weight, fewer of them will develop pre-eclampsia.  It is simply not possible to make such a conclusion at this point.

The IOM pointed out this problem in their report on weight gain recommendations.  So did Nohr 2008:
Any causal interpretation of the association between total weight gain and these complications is limited.  For pre-eclampsia, high total gain most likely reflects pathologic fluid retention as part of the disease.
I bet this issue gets no more than a passing mention (if that) in the Kaiser study when it's published.

Controlling for Iatrogenic Influences

Another major problem with these sorts of studies is whether they control for iatrogenic influences.

In other words, if doctors know how much weight women gain in pregnancy, this may strongly influence the outcomes.

For example, doctors are often of the firm belief that too much weight gain leads to too-big babies (marcosomia) and big babies "need" cesareans to prevent shoulder dystocia (the shoulders getting stuck and causing birth injuries).

Yet research clearly shows that when a doctor believes a baby to be macrosomic, the cesarean rate in that group skyrockets, even when the baby is not actually big.

Sometimes this is because doctors use higher rates of induction of labor when babies are believed to be big, and a number of studies show that induction of labor strongly increases the cesarean rate in macrosomic babies. However, sometimes it's also simply because the doctor is quicker to intervene and declare "failure to progress" or "cephalo-pelvic disproportion" when they believe the baby is macrosomic.

In other words, the doctor merely believing that the baby is going to be big influences the induction rate (increasing the risk for a cesarean), and influences how the doctor manages labor and decides to go to a cesarean.

And doctors believe that fat women have big babies when they gain "too much weight" in pregnancy.

So if doctors are not blinded to weight gains, it's quite likely that the low-gain "obese" women will have fewer cesareans and the high-gain "obese" women will have more......but it won't prove that more gain causes more cesareans. 

Instead it just creates a two-tier system where the "good" moms who gain within recommended parameters get more chances of avoiding a cesarean, and the "bad" moms who gain "too much" are penalized, consciously or unconsciously. 

Not blinding the doctors to weight gain to rule out iatrogenic influences is a serious design flaw of nearly all of these restricted weight gain studies. 

Too-Short Follow-Up for Mothers

Another concern is the lack of long-term follow-up for the mothers. 

One of the major goals of the study is to see if preventing weight gain reduces the mother's obesity long-term. 

Designing a study to have a short follow-up makes it easier for the study to look successful, which is why most weight loss studies have limited follow-up periods.  It makes them look more effective than they really are.

For example, the follow-up period of one year in this study is not nearly long enough to show a significant influence on the mother's weight. A follow-up of at least five years is necessary to make any conclusions about long-term improvements to health or permanence of weight loss.  This study doesn't have nearly enough length. Any study with such a short follow-up is trying to make their results look more favorable.

Sure, the less weight you retain after pregnancy, the better, so the one-year result is not irrelevant. But neither is it conclusive. Weight loss research clearly shows that most weight loss begins to disappear after a year to two years, and most will usually be regained if the study subject if followed long enough.

If followed long-term, often the subjects in weight loss studies end up heavier or with more belly fat than they began.  Will the subjects with no gain in this study have less total weight in five years, or will they merely experience a bigger rebound effect? 

This is an extremely important question...but it's one that's not being asked.

To follow up these mothers for only one year is not long enough to make real conclusions about their health or weight trends.

Lack of Long-Term Follow-Up for Babies

Most of these intervention studies look at very short-term outcomes, examine the babies for only extremely abnormal outcomes (like birth defects) right after birth, and proclaim the intervention "safe" if the baby is not harmed in any obvious way. But that doesn't mean the intervention really was safe, because harm is often more subtle than that.

A longer follow-up is vitally important to really determine the safety of restrictive gain protocols

In the New York Times article, this concern was briefly noted, pointing out that many fat women who lose weight during pregnancy produce large amounts of ketones, which may impair a baby's cognitive development.  Long-term follow-up is needed to determine whether cognitive development is impaired in babies whose mothers' weight gain is restricted, but no such follow-up is planned in the Kaiser study.  As the NYT article notes:
There are concerns. The major one is that women who are not gaining weight will burn fat for energy, producing acidic compounds called ketones, which could be harmful to the fetus. Studies in diabetic women and in animals have found that babies born to women who had more ketones in their blood had lower I.Q. scores than other babies, said Dr. Naomi E. Stotland, an assistant professor of obstetrics, gynecology and reproductive sciences at the University of California, San Francisco...
The Healthy Moms study will follow the women throughout their pregnancies to find out how much weight they gain, how big their babies are and how much weight they retain a year after the birth, looking at complications, the baby’s growth and feeding practices and whether the mother continues with a healthier lifestyle after the birth. Skeptics say they need to track additional measures, like the babies’ long-term cognitive development.
This is an extremely important point.  Possible cognitive effects from high levels of ketones is one of the major concerns that has not been addressed in any of these weight-gain restriction studies, and almost never is it even mentioned in the studies.  You cannot possibly conclude that major restriction should be the new norm without examining this question

Furthermore, we know from famine studies that babies who are exposed to famine conditions while in utero experience long-term health complications, including a tendency towards more diabetes, more high blood pressure, more heart disease, and more obesity.

In particular, babies who experience undernutrition in the womb but then are born into environments with plenty of nutrition have the highest risk for later problems.

I'm sure the women in this Kaiser will not be put on starvation diets like women in true famine conditions, but no one knows the long-term effects of milder rates of undernutrition. 

Messing with fetal nutrition is tricky stuff.  Human metabolism is incredibly adaptable, and babies often survive seemingly "fine" under horrendous conditions. Yet when you look at them long-term, this survival and adaptation often comes at a price. 

You simply cannot look at a baby immediately after it is born, note that it has not been born with any obvious birth defects, and then conclude that your highly restrictive program in pregnancy is beneficial or even perfectly safe. 

To determine real safety, there has to be long-term follow-up of babies in this type of program...but none of these programs have any.

How Do They Plan To Restrict Weight Gain?

Whenever one talks about restricting weight gain in obese women, the question becomes how do they plan to restrict gain, and what will they do to enforce it?

The Kaiser study doesn't really elaborate on specifics other than "two individual counseling sessions and then weekly group counseling," including weekly weighings and daily food and exercise diaries. Nor do they mention what will happen with "obese" women who gain weight anyhow.

If the plan is simply to discourage junk food and increase exercise, all well and good---but this would be good for all women, regardless of size.  Why just target fat women for this? People of all sizes eat "junk food" --- some in really significant amounts --- and it's not any better for the baby of a skinny woman than it is for the baby of a fat woman. And reasonable exercise is good for virtually everyone in pregnancy.  Why not emphasize healthy habits to all pregnant women?

(Answer: Because they have the typical assumption that all fat people eat terribly and need to be educated about their poor choices.)

If the program is just about emphasizing reasonable habits and targeting junk, great. Good nutrition and exercise in pregnancy is important. But if the plan goes beyond that and resorts to also limiting caloric intake, the question of relative fetal undernutrition comes into play, which raises a lot more questions about safety.

If they plan to strictly limit carb or caloric intake, do they plan to have participants test daily for ketones? If they are limiting calories and/or carbs, they should be checking ketones daily....but no mention of such monitoring is made in the press release.  Nor will they have long-term follow-up of babies subjected to these protocols.

The press release does not say how they will achieve "zero weight gain" in women of size, but it's hard to believe there will not be some degree of caloric restriction involved if they expect women to not even gain the weight of the baby, placenta and fluids.  How will they determine how many calories are enough, how will they monitor for problems, and how draconian will they get?

And what counselors will recommend if a "morbidly obese" woman actually gains weight in her pregnancy despite their program, as many probably will.....will she be told to restrict calories or carbs even more? Told to exercise in extreme amounts? Told to drink Slim-Fast? Will she be hassled about the gain?  Will she penalized with early induction or planned cesarean because she gained weight?  What happens to women who exceed the acceptable gain?  There's a lot of potential for problems here.

It's also important to point out that the question is not just what this particular study will be promoting, but also how OTHER doctors will interpret the "gain no weight" paradigm and what methods they will use to enforce this goal.

Fat women already report many harmful dieting practices being recommended to them in pregnancy in order to limit weight gain. Some women are merely told to eat less in pregnancy than when non-pregnant.  Some are told to drink Slim-Fast in pregnancy to limit weight gain. Others are told to limit their caloric intakes to 1800, 1500, or even 1200 or 1000 calories.  

And that was in the days when fat women were being encouraged to gain at least 15 pounds.

What kind of draconian recommendations will be made to "obese" women if they are supposed to gain no weight in pregnancy? Or to lose 10, 20, or even 50 pounds during pregnancy?  (Yes, those are all real recommendations told to women of size just recently.)

The question in studies like these is how restrictive is too restrictive, what follow-up is being done to see whether there is long-term harm with even mildly restrictive practices, and how other medical practitioners will go about incorporating and enforcing "no gain" mandates. 

This must not be glossed over, but is an important part of any study or public health policy that consideres seriously limiting pregnancy weight gain. Some doctors may limit weight gain in fairly reasonable ways, but other practices may resort to draconian interventions with a much higher potential for harm.

Is the Research Really Objective?

Finally, the fact that the researchers in this study are in bed with the weight loss industry is troubling; their results are going to be colored by that fact.

The Kaiser study employs a weight loss "expert" as a consultant; look at the language the "expert" uses in the press release: "For [the obese women], any more weight gain could be very dangerous."

"Any more weight gain could be very dangerous?" Does that sound like an objective observer to you? One open to any finding, even if it means finding the hypothesis invalid? Or does it sound like one who has already made his own conclusions, before the study is even done?

Just as we shouldn't trust the tobacco industry to come out with reliable findings on the safety of cigarettes, or should have a jaundiced eye when examining pharmaceutical research sponsored by drug companies, we shouldn't trust someone in the weight loss industry (which profits from consultations like this) to objectively conduct research on topics like weight gain restriction.

Many of these weight gain studies are rife with personnel who are on the staff of, consult with, or have a vested economic interest in weight loss companies and services.  And remember, consulting on weight gain restriction studies is a potentially vast new market for weight-loss companies and they know it.  They are hardly impartial bystanders in such research.

This is a tremendous conflict of interest but one that is rarely ever noted or questioned.

My Psychic Predictions

Putting on my all-seeing magic turban, I psychically predict that at the end of the Kaiser study, the women who gained less weight will have lower cesarean rates and less weight retention at the end of one year. Gosh, quelle surprise!

But is that really a function of the lower weight gain, or a function of the beliefs and practice patterns of their doctors? And of the small follow-up period?

It's one thing to propose a hypothesis and then do a study to collect data to see whether or not your hypothesis was correct. That's the scientific method.

However, that's not what these researchers are doing. They publicized the study before any results were even in because they are sure they know what results are going to be reached

Doing a study with a foregone conclusion is not good science. Furthermore, the study has to be of a size and design to accurately test your hypothesis; the Kaiser study is not. 

An objective study would look at all the possible benefits and risks from restricting weight gain, would be large enough and long enough to detect the real risk of harm associated with restricting weight gain, and would have no sponsors or associates who might benefit economically from a restriction program.

Yet very few of these restriction studies look at all possible harms, have large-enough sample sizes to detect harm reliably, and have long-term follow-up to detect more subtle harms. And many of them involve, directly or indirectly, researchers or consultants who are part of the weight loss industry.

The fact that they publicized the study heavily ahead of time in a major national publication, before the data was even collected or analyzed, strongly suggests that what they are really trying to do is push an agenda that NO weight gain is best for fat women, regardless of what the data actually say.

Conclusion

Again we are back to prenatal weight gain politics.

The bariatric obstetrics establishment is dismayed that the Institute of Medicine did not cave into their pressuring tactics and did not drastically lower their weight gain guidelines for obese women last year. They see it as a rebuke to the research and press releases they've published thus far.

So they are now pushing back with an aggressive marketing campaign designed to get out the message that fat women should gain very little in pregnancy. Except it's not enough anymore that fat women be kept to far lower weight gains than other women. 

No, now the research is taking a disturbingly extremist tone and pushing for NO gain and even weight LOSS, despite the fact that research shows some significant areas for concern (higher rates of prematurity, small-for-gestational-age babies, and possibly stillbirth) with very low gains, and despite that fact that restricted gain studies have major design flaws.
Now, to be fair, many who specialize in bariatric obstetrics probably truly feel that they are "saving" fat women and babies everywhere by promoting such draconian limits. They feel that the IOM is dragging its feet and endangering babies in the meantime.

And it's important to note that there is some research that really large weight gains (35 to 44 lbs. or more) may be harmful on average in "morbidly obese" women, resulting in higher rates of big babies, perineal trauma, postpartum weight retention, and perhaps perinatal mortality. So there is a case to be made that very high weight gains are not a good idea for women of size in general.

But without adequate (and far more thorough) study, it's impossible to establish the safety of very low weight gain limits.  And given previous and recent research, there is good reason to suspect that promoting weight loss or limiting weight gain too much could well produce more premature and/or small-for-gestational-age babies...or worse.

Even if these researchers don't make the IOM revise its guidelines any time soon, they know that aggressive marketing will start building an expectation in the public and in OB-GYNs that strictly limiting weight gain in fat women is "standard of care." 

We are already seeing this happen.  I'm hearing from more and more fat women that are being told that they are not allowed to gain ANY weight in pregnancy, or even that they must lose weight during pregnancy.

Increase attention to the importance of healthy eating and regular exercise in pregnancy?  I'm ALL for it, as anyone who knows my website and my past writings can attest.  I believe in Health At Every Size, and I believe that people should be gently encouraged to examine how they can improve their lifestyle and health, and never more so than in pregnancy.

Except I believe that such a program should be marketed to all women, regardless of weight/BMI, not just the fat ones.  Poor habits are not found only in "obese" women; care providers just assume that they are most egregious in this group.  But such attention to healthy habits would benefit many women and babies, and an emphasis on habits would be far more beneficial than a rigid emphasis on weight gain.

And creating rigid gain guidelines that may be unsafe and that have unrealistic expectations (zero weight gain or weight loss for all women of size) and which penalize anyone who falls outside those expectations (gained 21 lbs. in pregnancy?  It's planned cesarean for you!) is a terrible bastardization of what "healthy eating in pregnancy" programs should really be about. 

Remember that this study and press release is really about marketing limited weight gain to the public and to doctors, and that no conclusion about the safety of limiting gain in women of size has really been proven yet.

Far more research (and far better research) needs to be done to determine optimal prenatal weight gain in women of size. This Kaiser study is not it.

For now, I agree with the Cochrane Database, which concluded:
Protein/energy restriction of pregnant women who are overweight or exhibit high weight gain is unlikely to be beneficial and may be harmful to the infant.
Instead, the better approach may simply be to concentrate on excellent nutrition instead of prenatal weight gain. Barbara Luke, MPH and RD, summarized this in 1998 when she said:
Perhaps the obstetric goal should be to ensure optimal nutritional status during pregnancy, focusing on the quality and quantity of the preconception and prenatal diet rather than the crude and imperfect measure of gestational weight gain.
Commonsense words indeed.

Friday, October 8, 2010

Prenatal Weight Gain: Ignoring Possible Harms

We recently started a series discussing again prenatal weight gain politics for "obese" women. 

This was brought on by a press release from a Kaiser study started last year (and publicized in the New York Times, no less) about limiting weight gain in pregnancy for fat women, and by the Institute of Medicine's newly revised guidelines for weight gain during pregnancy earlier this year.

How much weight fat women should gain during pregnancy is a very hot topic in obstetric research currently.  There have been several major studies on the topic already, and there are certain to be many more in the future.  Doctors are salivating at the idea that perhaps the answer to concerns about risks in the pregnancies of women of size could be magically solved by simply limiting weight gain. 

Except the emphasis is going from "obese women should gain LESS weight" to "obese women should gain NO weight" to even "obese women should LOSE weight" during pregnancy...without even having proven the safety of restricted weight gain first.

It's not enough anymore that fat women be kept to far lower weight gains than other women; now the research is taking a disturbingly extremist tone and pushing for NO gain and even weight LOSS, despite the fact that research on limited weight gain already shows some major areas for concern.

As with the Kaiser study, these doctors have already made up their minds about limiting weight gain in fat women, and have decided that this is the message that needs to be pushed to consumers and other doctors.

The problem is that many of these studies have major study design flaws, but almost no one is taking a critical look at the research or asking whether these goals are really safe.  

Let's talk first about the real concerns for harm in weight gain restriction studies.

The Kaiser Study

To review, here are the 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.
Remember, the researchers publicized this study before they had even done the research.  This is not objective research, designed to test a hypothesis.  This is Science By Press Release, designed to push a pre-set agenda, even before they have data on its safety.

The title of the NY Times article was "New Goal for the Obese: Zero Gain in Pregnancy." Although the article briefly discusses the controversy over whether gaining no weight is safe, many people will come away from the article with the conclusion that no weight gain is the standard of care and the best goal for "obese" women during pregnancy. 

This is pure public relations marketing in order to push a public health agenda that has actually not yet been proven to be safe or effective.

This is only the first in a plethora of studies to come on little or no weight gain in pregnancy, as bariatrics obstetrics specialists push their agenda of strictly enforced weight gain in fat women.  But can studies like this one really conclusively decide the safety of such an approach?

Let's talk first about the possible harms that could come from strictly limiting weight gain in women of size.

Does The Study Report All Negative Outcomes of Interest?

One major concern is whether these researchers are really going to report all the possible negative outcomes that may be associated with low weight gain, like prematurity, stillbirth, cognitive impairment, or Small-For-Gestational-Age (SGA) and growth-restricted babies. 

In fact, many of these studies on restricting weight gain in "obese" women report only on the outcomes most likely to show benefit with restricted gains (like fewer big babies or cesareans), and have limited or no information about possible harms that can be associated with very low weight gains.  This is cooking the books in favor of a restriction agenda. 

An objective study would look at all the possible benefits and risks from restricting weight gain, and would be large enough and long enough to detect any real risk of harm associated with restricting weight gain.

Yet very few of these restriction studies look at all possible harms, have large-enough sample sizes to detect harm reliably, and have long-term follow-up to detect more subtle harms.

Let's talk about a few of the biggest concerns for harm with restricted gains.

Prematurity

Several of the studies on restricting weight gain in obese women fail to report prematurity rates, yet we know that low weight gains in pregnancy are strongly associated with higher prematurity rates. Yes, the effect is less strong in obese women, but research clearly shows the association is still there.

For example, Shieve found that the magnitude of risk for prematurity with low gain varied by BMI but was still 1.6x for "overweight" women. Nohr also found that low weight gain was associated with an increased risk for preterm birth.

Dietz found an increased rate of very preterm birth with very low weight gain among women of all BMIs.  The effect was strongest in underweight women, but the risk was still more than doubled in "very obese" women.

So prematurity is still a concern with very low weight gains, even in significantly heavy women.  If a restricted gain study does not report on prematurity rates (or does not have sufficient sample size to give it the power to detect a difference in prematurity rates), it is not safe to conclude that low weight gains in obese women is safe or desirable.  Yet these studies often do so.

Stillbirth

Another complication that is almost never examined in these studies is the rate of stillbirth. Because stillbirth is a rare complication, very large data sets are needed to examine the impact of low weight gain on stillbirth, and most of these studies do not have large enough data sets.  So most do not examine the question of stillbirth, yet still routinely conclude that low weight gain is "safe" and results in "better outcomes."

However, one older study that prospectively followed the pregnancies of more than 53,000 women found that "overweight" women had more fetal and neonatal deaths with very low gains (less than 6 lbs.).  They noted:
Even large stores of depot fat do not seem to ensure an optimal outcome of pregnancy when weight gains are very low or mothers lose weight.  Overweight mothers in the lowest weight gain category had perinatal mortality rates twice those of overweight women with somewhat larger gains.
A recent 2009 study confirms the concern about a possible association between very low weight gain and an increased risk for neonatal and infant death, even in "obese" women. 

Clearly, the subject needs more research before a conclusion is reached, but it is vital that this question be examined more closely before the "safety" of restricted gain programs is proclaimed.

The Kaiser press release merely notes that they will "look at" birthing complications. That might include prematurity and stillbirth---but it might not. Instead it may simply be looking at things like shoulder dystocia, cesarean rates, and birth injuries, as many of these studies do, while conveniently ignoring poor outcomes like prematurity or stillbirth.

Neither prematurity nor stillbirth are all that common an occurrence. Is a study sample of 90 women in the intervention group really enough to draw conclusions about prematurity, stillbirth, or the overall safety of a "zero weight gain" policy?

Ketonuria and Cognitive Impairment

In the New York Times article about the Kaiser study, the question of ketones was briefly raised. 

Ketones are produced when the body does not have enough energy for the baby and so it turns to burning fat for its needs. Some research in the past has tied consistent/high levels of ketones in the urine (ketonuria) to impaired cognitive development in the child.

Yet most of these restricted gain studies do not monitor for ketones on a daily or even weekly basis

Ketones are usually a sign that the mother's diet is too low in calories and/or carbohydrates for her needs.  If no one monitors for ketones on a frequent basis, the researchers will not know if anyone's diet needs adjusting and those babies will continue to be exposed to large amounts of ketones.  Furthermore, there does not seem to be a plan for any long-term follow-up to see whether cognitive development is normal. 

As noted in the NYT story:
There are concerns. The major one is that women who are not gaining weight will burn fat for energy, producing acidic compounds called ketones, which could be harmful to the fetus. Studies in diabetic women and in animals have found that babies born to women who had more ketones in their blood had lower I.Q. scores than other babies, said Dr. Naomi E. Stotland, an assistant professor of obstetrics, gynecology and reproductive sciences at the University of California, San Francisco.
“What we don’t know is: Are there effects on the babies’ neurological development, or other adverse effects, from women not gaining weight?” Dr. Stotland said. “Some of these women may be losing fat mass, and the question is: Is losing fat mass during pregnancy, when you’re in a higher B.M.I. category, is that safe for the baby?”

Unfortunately, most of these restricted gain studies don't even bother to ask that question by monitoring for ketones or doing long-term follow-up of the babies.

Small for Gestational Age

One very common side effect of too-little prenatal weight gain are infants that are "small for gestational age" (SGA). 

Although the effect of low weight gain is less strong in women of size, the effect is still there. Several studies on weight gain in "obese" women have found that low weight gain is associated with an increased risk of SGA babies, even in very fat women.

For example, the Missouri study of birth certificate data found that while little or no weight gain in "morbidly obese" women resulted in lower rates of pre-eclampsia, large babies, and cesarean sections, it also strongly increased the risk for small-for-gestational-age babies.

The authors shrugged this finding off as unimportant, concluding, "Limited or no weight gain in obese pregnant women has favorable pregnancy outcomes."  Since when is a baby born small for its age a "favorable outcome"?

The study looked at the rates of pre-eclampsia, big babies, cesareans, and SGA and tried to develop "optimal gain" ranges where the risk for all these various adverse outcomes being lowest met.  But they considered a 10% SGA rate acceptable in these tradeoffs.  However, is a 1 in 10 SGA rate really a "favorable" outcome?  That's a lot of too-small babies.

A very large study from Sweden showed similar results.  "Obese" women who gained less than 17 lbs. in pregnancy had lower risks for pre-eclampsia, cesareans, instrumental delivery, and big babies BUT also had 1.68x the risk for an SGA baby (which they conveniently neglected to mention in the study's abstract).  One has to wonder what the risk for SGA would have been with a weight gain close to zero, which is what many of the newest studies are proposing.

A number of other studies have also found that low gestational weight gains are associated with higher rates of SGA babies.  Parker found that "obese" women with very low weight gain more than doubled their risk for SGA babies compared to "obese" women with normal gains by IOM standards.

Edwards found that "obese" women who lost or gained no weight were nearly 3x more likely to deliver SGA infants than those who gained 15-25 lbs.  Of those who lost weight during pregnancy, 11% had SGA infants.  Again, that's a lot of too-small babies at risk for problems.

In addition, Cogswell evaluated data from more than 53,000 women in 8 states and found that "very overweight" women who gained less than 15 lbs. in pregnancy had a 1.5x risk for a low-birthweight baby. 

Recent research suggests that data probably needs to be stratified by class of obesity.  In other words, the risks of SGA with weight loss or very low weight gain in just-barely "obese" women is a lot stronger than the risks of SGA with low gain or small loss in "morbidly" obese women. 

That's a valid point.  The problem is that most doctors do not make this distinction, instead telling most obese women that they need to drastically curtail their weight gain.  And certainly the media message being promoted these days by the Obesity Mafia is that ALL fat women should gain little or no weight in pregnancy....and they are not making distinctions between classes of obesity.  Nor does the Kaiser study seem to be distinguishing between classes of obesity in its study.

The take-home message that most fat women will hear is not to gain any weight in pregnancy....and this could well increase the rate of too-small babies, especially among mid-sized fat women.

However, the fact that the risk for SGA is less strong in "morbidly obese" women doesn't mean that very low weight gains is perfectly safe even in this group either.  It simply means we need more study on the topic to further examine the outcomes in this subgroup. 

Balancing the Risks of Harms vs. Benefits

Weight gain restriction studies trumpet the fact that "obese" women who gain less weight tend to have lower rates of various complications like big babies, pre-eclampsia, and cesareans.  This sounds like a great thing on the surface, but the benefits of those things have to be weighed against the potential for major harm that may come from a premature or SGA baby that results from restricted gains. 

Research shows that low-birthweight babies often face life-long health complications and risks, probably moreso than large babies or babies born by cesarean. Yet these studies routinely place more importance on avoiding large babies and cesareans and discard the finding of increased rates of SGA babies as unimportant.

This is the change in obstetric risk perception that has occurred in maternity care over time.  For many years, in the 1940s-60s, doctors emphasized low weight gains as a way to "prevent" problems like pre-eclampsia. In time it became apparent that the weight gain recommendations were so low that many babies were being born underweight or prematurely. 

In the 1970s and 1980s, a slow reform took place, permitting more weight gain as a way to prevent SGA and premature babies.  The Institute of Medicine weight gain guidelines reflected that.

Now, with the obesity hysteridemic, weight gain in pregnancy is once again under attack.  Some doctors advocate strictly limiting prenatal weight gain for all women, but particularly so for "obese" women.  They see this as the "magic bullet" to prevent pregnancy complications and prevent long-term obesity problems. 

The problem is that the tradeoff means more premature and small-for-gestational-age babies.....a trade-off they find acceptable, but which is questionable, given the really significant long-term health risks of SGA babies. 

Cedergren, author of the 2006 Swedish study mentioned above, echoed this dilemma when she concluded, "What conclusions you draw depends on how you value the adverse effects."  In other words, is a decrease in cesareans and big babies worth an increase in unhealthily-small babies?

I don't believe it is.  SGA and growth-restricted babies face life-long health risks and increased risk for stillbirth; the data is less clear on the effects of macrosomia, with some research suggesting that SGA babies are worse off than LGA babies. 

If I had to choose, I'd rather gain a little more weight and risk a bigger baby than to lose weight or gain almost nothing and risk an unhealthily-small baby, putting it at risk for possible stillbirth or life-long health problems.

But big babies are the ultimate "boogeyman" in the obstetric world these days.  How sad that doctors would rather risk more SGA babies than learn how to deal more effectively with big babies.

Furthermore, these studies do not really prove that restricting weight gain prevents cesareans or pre-eclampsia.  It may simply be a coincidental finding because of study design and iatrogenic issues.  (But that's the topic of the next post!)

But in the meantime, it's important to remember that while many "obese" women gain little in pregnancy and are perfectly fine, some "obese" women gain little and have higher rates of premature babies, SGA babies, and stillbirths. There ARE potential harms that come along with rigid gain-restriction policies.

*Next Up:  Study design limitations of weight-gain restriction studies.