Tuesday, August 30, 2016

Mammograms: Getting Called Back for Additional Testing

At some point in a woman's life, she should start having regular mammograms. When she should do this is a matter of some controversy, but sooner or later, most women will have regular mammograms every year or two.

But what happens when you get a call back after your mammogram telling you that you need further imaging? What can you expect, and how likely is it that you will be diagnosed with breast cancer? How can you handle the anxiety while waiting for further results? Where can you get further support and information?

Earlier this year, this happened to me. I had my regular mammogram and got a call back telling me they had found two suspicious areas and I needed further testing. It was very unsettling. Even though intellectually you understand it's not an actual diagnosis of cancer, it feels like a sentence of doom. Your anxiety levels go through the roof.

Statistically, only a few women who get called back for additional testing after an "abnormal" mammogram result actually have cancer. Most are just fine, but many of those called back have fears about what additional testing entails.

Let's talk about what diagnostic mammograms are, what additional testing may be used, what to expect during the appointment, how to handle the waiting, and the latest screening guidelines. Then I'll share with you my diagnostic testing experience.

First Step: Don't Panic

Although it's deeply unnerving to get "the call" telling you to get more testing, the first step is to stay calm. Don't panic and start mentally going to worst-case scenarios. As one resource notes (my emphasis):
If doctors find something suspicious, they’ll call you back – usually within just 5 days – to take new pictures or get other tests. Getting that call can be scary, but a suspicious finding does not mean you have cancer. In fact, less than 10% of women called back for more tests are found to have breast cancer.
Although your mind will tend to automatically assume the worst, take a deep breath. Remind yourself that even when extra testing is required, you have a 90%+ chance of not having cancer. 

It's normal to cycle in and out of various "what-if" scenarios in the time before your diagnostic test, but the important thing is to focus as much as possible on the other business of your life. There's no need to panic when you don't know if there's something to actually panic over.

It's understandable to do some worrying, but don't let it consume you. Hard as it is, try not to focus on the uncertainty; let the future take care of itself. Focus instead on the everyday tasks of your life.

Screening vs. Diagnostic Mammograms

An important aid in avoiding panic is to remember that there is a major difference between a screening test and a diagnostic test.

A diagnostic test tells you for sure whether or not you have a certain condition. To get that kind of certainty, diagnostic tests are very involved, expensive, and time-consuming. Because of the time and expense, it simply does not make sense to order them for everyone.

Therefore, a simpler and less-expensive test is used on everyone ─ a screening test. Screening tests are designed to test a wide variety of asymptomatic individuals to look for problems that might need a closer look. These tests are slanted towards what's called "sensitivity" ─ a high chance of finding any existing problems ─ so as not to miss any potential disease. The trade-off is that many people (including many who don't have the disease) will require additional diagnostic testing, and that testing process can be unnerving.

Diagnostic testing looks specifically for disease or a high suspicion of disease. It is geared towards "specificity" ─ accuracy in ruling out disease. If something pops up on the screening test that is unusual or statistically outside of the norm, that person is called back in for further testing. [Of course, anyone with a distinct symptom of a disease goes straight to diagnostic testing.]

This arrangement of starting with a screening test and only going to a diagnostic test for a few people is a smart way to save time and money in an era of limited medical resources. But because most of the public doesn't understand the difference between a screening and diagnostic tests, many people automatically assume that a call-back means they likely have cancer. It doesn't.

Handling the Anxiety of Waiting

Even for people who understand screening vs. diagnostic testing, call-backs can still feel quite alarming. Human nature makes us emotionally jump to worst-case scenarios. That's why you have to keep reminding yourself not to panic. The best thing to do is simply to focus as much of your attention as possible on the tasks of everyday living and not dwell on the fear. Find ways to redirect your anxiety.

Of course, just telling yourself not to worry may be counterproductive; it may be easier instead to let yourself worry but to limit the amount of time spent on it. If you find yourself being taken over with worry, try writing down your worries, putting them into an envelope (physical or mental), and taking them out to indulge the worry only at specified times. When you do indulge the worries, let yourself do it in depth. Think of every worst-case scenario you can, weep and wail, write your good-bye letters, plan your funeral, etc. But then at the end of the specified time, stop and put those fears away until next time. By indulging your fears periodically, you lessen their emotional dominance the rest of the time. It's the rigidly suppressed fear that tends to multiply. Let yourself express your worries but it may help to put some limits on that expression.

Another thing that can help is to journal about why you are so worried. Do some stream-of-consciousness writing to explore your fears. Often the answers seem simple when you start, but the writing process helps uncover more subtle reasons that can give you insight. Journaling won't make the worry go away but understanding the true source of the anxiety may help diffuse its power so it is less emotionally overwhelming.

It's only natural to worry, but try to keep the worry in perspective, try to understand it, and find ways to deal with it that keep it from taking over your life. Soon you will have the answers that you need and can either relax or start developing a positive plan of action. If you need additional support, don't forget that many cancer organizations have 24 hour free phone lines for information and support.

Follow-Up Testing: What to Expect

When you return for follow-up testing, what can you expect?

Basically, plan to devote about half a day to the appointment, give or take. Remember not to wear any powder or lotions to the appointment. Bring a book to help occupy yourself while waiting. The appointment will take several hours and quite a bit of this will be waiting.

You will start by having a longer and more in-depth mammogram. More images will be taken, using more angles, so they can really focus in on the area in question. Although longer than a normal mammogram, this process is usually less than an hour. Don't be afraid to ask questions about the process; technicians are limited in what they can say (and obviously can't give a diagnosis), but often can offer insight into what is being looked at and why.

Next comes the ultrasound. Although not mandatory, most mammography centers also do an ultrasound of the breast during follow-up testing. This process is also around an hour and will examine closely any areas of concern on the breast as well as lymph nodes underneath the arm.

Sometimes an MRI is also done. This is not considered standard-of-care and may not be covered by insurance so it is not part of most routine follow-up testing at this time.

You will be asked to wait on site while a radiologist reviews the results. This can take an hour or two more, so be prepared to wait, but you should get the results that day. The results are usually one of the following:
  • The suspicious area turned out to be nothing to worry about and you can return to your regular mammogram schedule
  • The area is probably nothing to worry about, but you should have your next mammogram sooner than normal – usually in 4 to 6 months – to make sure it doesn’t change over time
  • Cancer was not ruled out and a biopsy is needed to tell for sure
Remember, even if a biopsy is recommended, chances are you still don't have cancer. Often biopsy results are benign. This is hard to remember when you are told you need a biopsy but it's important to keep reminding yourself of this fact.

There are different types of biopsies. Most are done with a needle but some need a small incision. Biopsy results have to be sent away for analysis, which can take anywhere from a few days to a week or two. The wait is difficult. Find some emotional support but don't forget to keep your focus on normalcy during daily life.

If your biopsy results are benign, ask the doctor whether any follow-up is needed and when your next mammogram should be. Get the results and recommendations in writing for future reference.

If your biopsy results show cancer, then it is time to consult a breast specialist. People often report difficulty in recalling the information given at these consultations, so take a knowledgeable and supportive friend or relative with you to the appointment. Ask to record the appointment so you can refer back to it later. Take notes (or have your support person take notes) and ask for correct spellings of any words you don't know so you can research it further. You can find a list of questions to ask here.

Don't be afraid to ask for a second opinion about your options. You can you get completely different advice from another care provider so it really is worthwhile to get a second (or even third) opinion. You can also call the American Cancer Society for information and support at 1-800-227-2345. Many additional online resources for support also exist; don't be afraid to reach out to them. Many women find it helpful to be paired with someone who has been through breast cancer themselves and is trained in offering support to newly-diagnosed patients.

Reminder of Screening Guidelines

With all the anxiety that a positive screening test can generate, it's no surprise that many women opt out of yearly mammograms. They simply don't want to deal with the anxiety it produces. Others are concerned about over-treatment for non-aggressive cancers, false-positives, and the cumulative effect of the radiation from many mammograms.

Yet we know that statistically, mammograms save lives, especially as women age. So when should women start getting mammograms?

Unfortunately, even the experts can't agree on how often women should have mammograms. Some organizations suggest regular screening start at 40, some suggest 45, some suggest waiting till 50.

Once you do start regular screening, some suggest that every 2 years is enough, while others strongly push yearly screening. It's hard to know what to do.

From cancer.net, Dr. Connie Lehmen gives a summary of the controversy over screening guidelines:
At an absolute minimum, women should begin screening mammography no later than age 50 and get a mammogram every 1 to 2 years until at least age 74. All medical organizations agree with these minimum recommendations for screening...The areas of disagreement, and reasons for differences in the recommendations from different groups, center around the age to begin screening (40, 45, or 50) and the interval of screening (every year or every 2 years). These variations are due to different groups of people who interpret clinical trial data differently.
Bottom line, when you start and how often you screen really depends on your risk factors. Recommendations will vary from woman to woman.

How does "obesity" figure into recommendations? That's harder because it's not always clear. We do know that high-BMI women are less likely to get regular mammograms or follow-ups after abnormal mammograms, which may partially explain why we tend to be diagnosed at more advanced stages of cancer. Yet there is only limited research and recommendations specifically on the trade-off of benefits and risks of screening in obese women at different ages.

As women of size, it is clear that we are at increased risk for post-menopausal cancer ─ but authorities often neglect to mention that we are generally at decreased risk for pre-menopausal breast cancer (except triple negative breast cancer). But when does that initially decreased risk cross over to increased risk? Is it a hard and fast conversion right at menopause, or a gradual increase of risk as you approach menopause? I don't think anyone really knows for sure.

That means it's particularly hard to know what mammogram schedule a woman of size should follow during that in-between time in the 40s when women are peri-menopausal.

The short version is that mammogram decisions then really seem to boil down to your other risk factors (especially family history, breast density, and blood sugar status) and becomes a personal choice you decide in consultation with your healthcare provider.

Personally, not having access to much family medical history and having had a lot of fibrocystic lumps, I had a number of mammograms in my 20s and 30s. In retrospect, I think we did too much. After a lot of research, I opted out of yearly mammograms in my 40s, but did have a couple to establish a baseline. Now that I am past 50 I think it sensible to get regular mammograms (about every year or two) because high-BMI women really are at increased risk for post-menopausal breast cancer.

I still don't love mammograms but have found a center where the care is more sensitive and gentle than I've experienced in the past. It's still anxiety-producing but regular mammograms seem a sensible precaution at my age.

But that's just my choice, based on my own circumstances. Yours may be completely different.

My Experience with Call-Back Testing

Needing a follow-up diagnostic mammogram really threw me. It just goes to show that having intellectual knowledge about a subject doesn't always have a lot to do with how you react to unsettling news.

Even though intellectually I knew that I probably didn't have cancer, I'm very good at "catastrophizing." It took quite a bit of effort to reel back my tendency to immediately go to the worst-case scenarios. Reading up about screening vs. diagnostic testing helped me scale back some of my fears. Education can be a powerful counter to fear.

When the anxiety elevated despite my reading, I made an effort to explore it. Obviously I was deeply concerned about leaving my children motherless, especially because I still have a young one at home. But upon further reflection, I realized that my fear was made worse by the fact that my husband had just been laid off. My big concern was that if I did have breast cancer, we'd run out of health insurance and I'd bankrupt the family and cause us to lose our house. We also have two kids in college, another in high school heading off to college soon, and the young one in private school; I was worried that my medical bills would derail their educations.

For me, handling the anxiety proactively while waiting needed multiple approaches. Research helped reassure my rational mind that I had a 90% chance of not having cancer. Emotionally, taking the time to explore why the fear was persistent helped me understand and diffuse a lot of its power. I was then better able to just focus on the everyday tasks instead of spending my days in constant fear.

In the end, I didn't have cancer, just some "asymmetrical lymph nodes" that the radiologist initially flagged but ultimately considered normal. I don't even have to go back for more frequent testing, just the normal screening.

Whew, what a relief! But oh, how difficult that waiting period is. Especially coming during a job layoff and time of great stress at my own work.

Sadly, there are no magical answers to getting through it; for me doing research and exploring my fears was vital in staying sane. In the end, though, it really boiled down to gritting my teeth and focusing on everyday tasks so I didn't go crazy.

It's totally normal to be anxious while waiting. But if that anxiety gets overwhelming, consider what is effective for you to deal with the worry. Consider developing some additional tools to help.

Has anyone else gone through a similar experience? What helped you get through the waiting period?


Thursday, August 18, 2016

"Safe" Gestational Weight Loss?

Graphic from this misleading article. The article addresses
improving diet and exercise in pregnancy but doesn't mention any
of the studies that show risks associated with weight loss in pregnancy
While researching another post, I was angered to see that some providers ─ and media outlets ─ are still worshiping at the altar of weight loss in pregnancy for "obese" pregnant women.

Augh! I can't believe this is still being promoted, even after a number of studies suggesting there are risks to gestational weight loss.

I know, I know. Many care providers hope weight loss in pregnancy is the magical pill to automatically improve pregnancy outcomes in women of size and leave them forever skinnier afterwards. They see it as a theoretical win-win. But it just doesn't happen this way ─ and it is associated with significant risks. That is not a win-win situation.

Too many authors extol the possible benefits of gestational weight loss (GWL) while significantly downplaying or completely ignoring the possible risks.

I find this incredibly frustrating and irresponsible.

Ignoring the Evidence for Harm

In the article accompanying the graphic above, for example, the author never addresses the potential risks of losing weight during pregnancy. A fair and balanced article ought to look at both benefits and risks, but it doesn't.

The article suggests improving diet and exercise in pregnancy and notes some potential benefits from that. I don't have a problem with promoting good habits and agree that sometimes this may prevent certain complications, but the article makes the typical biased assumption that all fat women have terrible habits. This promotes the stereotype of the gluttonous obese person, which just doesn't match the life experience of the many fat people who have normal habits. So the article is problematic already for its automatic assumptions.

More importantly, the author never mentions any of the studies which have found risks associated with gestational weight loss. This is intellectually dishonest and shows an obvious agenda. The author implies that it's perfectly safe to lose weight in pregnancy, even though the issue of safety was not actually addressed in the article.

So what does the research say?

Over and over again, researchers have found that weight loss in pregnancy is associated with too-small babies and possibly prematurity.

In one study highlighted below, for example, "overweight" and "obese" women who had been diagnosed with gestational diabetes were enrolled in the California Diabetes and Pregnancy Program. Those who lost weight were compared with those who did not. 

The authors found that gestational weight loss was associated with some problematic outcomes, including more Small-for-Gestational-Age (SGA) babies and more premature babies. But this study is not the only one to find risks with Gestational Weight Loss (GWL). Here are a few more that have also found problems:
  • Bodnar 2010 - GWL increased risk for SGA and preterm births among obese women
  • Bayerlein 2011 - GWL increased risk for SGA and preterm births in all but class III obese women
  • Blomberg 2011 - GWL increased risk for SGA even among class III obese women
  • Catalano 2014 - GWL more than doubled the risk for SGA among obese women
  • Cox Bauer 2016 - GWL doubled the risk for low birth weight babies
As a result, one recent meta-analysis concluded:
GWL should not be advocated in general for obese women.
Yet there are still far too many doctors, midwives, and media articles promoting just that.

An Acceptable Trade-Off of Risks?

Critics will point out that gestational weight loss has benefits that off-set the increased risk of SGA and prematurity. For example, in the California Diabetes and Pregnancy Program study above, women who lost weight during the study experienced decreased risks for a big baby (macrosomia or LGA), cesarean sections, and NICU (Neonatal Intensive Care Unit) admission. The authors felt that this trade-off was good enough reason to promote continued inquiry into gestational weight loss, despite the increased risks for SGA and premature babies.

But these arguments have a huge fault in them ─ ignoring iatrogenic (physician-caused) variables. For example, when doctors see a large woman with a larger weight gain, they fear macrosomia and shoulder dystocia. As a result, they may disproportionately induce those who gained more weight and have a low surgical threshold for cesareans in this group. Thus, a higher cesarean rate in this group be more a reflection of their doctors' fears and intervention levels rather than an actual causal effect a larger gain.

Furthermore, a higher induction rate could also explain increased NICU admissions in this group, since induction places increased stress on the baby. Also, bigger babies receive more surveillance for possible low blood sugar, which often entails a trip to the NICU. So while the increased NICU admissions in the weight gain group cannot be dismissed, it may also simply be a surrogate marker for increased interventions in this group.

Only fetal size is directly linked to weight gain in pregnancy. Very high gains lead to bigger babies on average, and avoiding very high gains is probably a good idea. However, that doesn't mean that pressuring women to lose weight in pregnancy is better.

SGA has serious potential consequences, yet this is shrugged off as being fairly unimportant by many researchers. They feel it is worth the trade-off for fewer big babies. Culturally, big babies are the ultimate "boogeyman" in the obstetric world these days because OBs are often sued for birth injuries caused by shoulder dystocia. Yet drugging women, forcing them to birth on their backs in immobile positions, and rushing the baby out too quickly have a lot to do with shoulder dystocia and birth injuries. How sad that doctors would rather risk more SGA babies than learn how to deal more effectively with big babies.

I am alarmed at the number of care providers and researchers who consider SGA and prematurity a "minor" matter and a worthwhile trade-off.

SGA and prematurity are significant concerns for babies because they are at increased risk for fetal death, sudden infant deathcognitive delay, and poor neurodevelopmental outcomes.

SGA babies also tend to have more significant downstream health effects like metabolic disease, including insulin resistance, diabetesmetabolic syndrome, and cardiovascular disease. SGA and growth-restricted babies face life-long health risks.

It doesn't end there. SGA babies are clearly at increased risk for stillbirth. And there is now research shows that SGA babies of obese women are at particular risk for stillbirth. Stillbirth!

Additionally, recent research shows that obese women with gestational weight loss had higher risks of infant death after birth.

Yes, macrosomia has risks too, like higher rates of shoulder dystocia and birth injuries, and possibly higher cesarean rates.

However, some research suggests that SGA babies are worse off than LGA babies. And having a bigger baby on average may be nature's way of protecting the babies of high-BMI women, since stillbirth risks are lower among LGA babies than among SGA or average-sized babies in obese women.

Personally, if I had to choose, I'd rather gain a little more weight and risk a bigger baby than to lose weight and risk an unhealthily-small baby, putting it at risk for possible stillbirth or life-long health problems.

Yet researchers continue to shrug off SGA as a minor thing. The author of one study on limiting weight gain in obese women said, "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 say NO. SGA babies need to be taken far more seriously as a downside to very low weight gains and weight loss in pregnancy, even if the price is a few more big babies or possibly even a few cesareans.

Or better yet, care providers could learn how to attend the birth of a big baby more safely.

The best route to improve outcome may be to address fears and intervention levels around big babies rather than to make all fat women lose weight in pregnancy and risk too-small babies.

Take-Away Messages

Messages like this are irresponsible and need to stop
Websites that promote weight loss during pregnancy still abound in the media, and articles are still being published that say that weight loss in pregnancy is "safe" (I refuse to link to them).

And some doctors are still advising overweight and obese women to lose weight during pregnancy. Dr. Thomas Myles, a professor of obstetrics and gynecology at Saint Louis University School of Medicine, said in one article, "I usually tell my [obese] patients that gaining less than 10 pounds and even losing up to 10 pounds is appropriate."

Doctors and the media need to stop promoting weight loss in pregnancy for obese women. 

We've talked about this extensively before but despite the studies showing risks, the media and many providers keep promoting it. This is potentially dangerous.
Yes, some women of size naturally lose weight in pregnancy or gain very little. As long as they are not restricting calories to lose weight, have good overall nutrition, and their babies show normal growth curves, their outcomes are usually fine. I'm not worried about women who lose a little weight incidentally. Sometimes that happens in larger women and it's not a big deal.

Nor am I worried about care providers encouraging good basic nutrition principles and regular exercise in women (although I think they should do that for all women and not just fat women). Good nutrition is a basic and ALL pregnant women should be encouraged to work on it, though I would challenge providers to find a way to talk to their clients about nutrition and weight gain without condescension, moralizing, and automatic assumptions.

What I am deeply worried about is encouragement for women of size to intentionally lose weight in pregnancy, and the dangerous nutritional advice that is being given to some obese women in order to promote this dubious goal. 

For example, one doctor told his patient to "lose 1-2 lbs/week for the remaining 7 weeks of pregnancy...He suggests 1000 calories/day and 1 hour of heavy cardio exercise." Others have been told that they should lose 40 lbs. while pregnant, or that the baby will get all it needs from fat reserves so it's okay to lose weight. A few care providers are telling obese women to cut out entire food groups ("never eat carbs" or "cut out all fruit"), to go on SlimFast shakes, or to "eat nothing but vegetables" in order to limit weight gain.

Although most doctors are not this extreme, some women are being pressured into some dangerous nutritional stuff, all in the name of gestational weight loss. And women are being pressured into more interventions (like unnecessary inductions and planned cesareans) if they gain above what their care providers think they "should" be gaining.

Researchers MUST start recognizing the fact that their well-intentioned studies on restricted weight gain in obese women are, in practice, resulting in very harmful dietary advice and punitive practices for women who gain "too much."

Promoting gestational weight loss may be doing FAR more harm than good in obese women, especially those in borderline BMI categories for whom GWL is particularly risky. But even in "morbidly obese" women, there is enough evidence of possible harm that care providers should not be pushing for intentional weight loss in pregnancy.  

Instead, I urge care providers to focus on:
  • Reasonable nutrition
  • Regular exercise
  • Proactive care protocols 
In addition, caregivers MUST start looking at their own practice patterns in response to obese mothers' weight gain (especially induction for big baby) and how this impacts cesarean rates, NICU admissions, and morbidity in high-BMI women and their infants.

Here's what I want researchers and media to change:
  1. Stop promoting weight loss in pregnancy for obese women 
  2. Stop trying to sell gestational weight loss as "perfectly safe" and acknowledge the research that shows significant risks with it 
  3. Start recognizing that providers' responses to obese women's weight gain impacts outcomes, perhaps more than the gain itself
  4. Learn how to attend the births of big babies more safely 
Stop focusing so exclusively on the scale and start focusing on reasonable habits and reducing interventions as ways to improve outcomes in high-BMI women.


Obesity (Silver Spring). 2013 Apr 24. doi: 10.1002/oby.20490. [Epub ahead of print] Gestational weight loss and perinatal outcomes in overweight and obese women subsequent to diagnosis of gestational diabetes mellitus. Yee LM, Cheng YW, Inturrisi M, Caughey AB.  PMID: 23613187
OBJECTIVE: To investigate whether gestational weight loss after the diagnosis of gestational diabetes mellitus (GDM) in overweight and obese women is associated with improved perinatal outcomes...METHODS: Retrospective cohort study of 26,205 overweight and obese gestational diabetic women enrolled in the California Diabetes and Pregnancy Program. Women with gestational weight loss (GWL) during program enrollment were compared to those with weight gain...RESULTS: 5.2% of women experienced GWL. GWL was associated with decreased odds of macrosomia (aOR 0.63, 95% CI 0.52-0.77), NICU admission (aOR 0.51, 95% CI 0.27-0.95), and cesarean delivery (aOR 0.81, 95% CI 0.68-0.97). Odds of SGA status (aOR 1.69, 95% CI 1.32-2.17) and preterm delivery <34 weeks (aOR 1.71, 95% CI 1.23-2.37) were increased.  CONCLUSIONS: In overweight and obese women with GDM, third trimester weight loss is associated with some improved maternal and neonatal outcomes, although this effect is lessened by increased odds of SGA status and preterm delivery. We recommend further research on weight loss and interventions to improve adherence to weight guidelines in this population.
BJOG. 2011 Jan;118(1):55-61. doi: 10.1111/j.1471-0528.2010.02761.x. Epub 2010 Nov 4. Associations of gestational weight loss with birth-related outcome: a retrospective cohort study. Beyerlein A1, Schiessl B, Lack N, von Kries R. PMID: 21054761
...DESIGN: Retrospective cohort study. SETTING AND POPULATION: Data on 709 575 singleton deliveries in Bavarian obstetric units from 2000-2007 were extracted from a standard dataset for which data are regularly collected for the national benchmarking of obstetric units...RESULTS: GWL was associated with a decreased risk of pregnancy complications, such as pre-eclampsia and nonelective caesarean section, in overweight and obese women [e.g. OR = 0.65 (95% confidence interval: 0.51, 0.83) for nonelective caesarean section in obese class I women]. The risks of preterm delivery and SGA births, by contrast, were significantly higher in overweight and obese class I/II mothers [e.g. OR = 1.68 (95% confidence interval: 1.37, 2.06) for SGA in obese class I women]. In obese class III women, no significantly increased risks of poor outcomes for infants were observed. CONCLUSIONS: The association of GWL with a decreased risk of pregnancy complications appears to be outweighed by increased risks of prematurity and SGA in all but obese class III mothers.
Obstet Gynecol. 2011 May;117(5):1065-70. doi: 10.1097/AOG.0b013e318214f1d1. Maternal and neonatal outcomes among obese women with weight gain below the new Institute of Medicine recommendations. Blomberg M1. PMID: 21508744
...METHODS: This was a population-based cohort study, which included 32,991 obesity class I, 10,068 obesity class II, and 3,536 obesity class III women who were divided into four gestational weight gain categories. Women with low (0-4.9 kg) or no gestational weight gain were compared with women gaining the recommended 5-9 kg concerning obstetric and neonatal outcome after suitable adjustments. RESULTS: Women in obesity class III who lost weight during pregnancy had a decreased risk of cesarean delivery (24.4%; odds ratio [OR] 0.77, 95% confidence interval [CI] 0.60-0.99), large-for-gestational-age births (11.2%, OR 0.64, 95% CI 0.46-0.90), and no significantly increased risk for pre-eclampsia, excessive bleeding during delivery, instrumental delivery, low Apgar score, or fetal distress compared with obese (class III) women gaining within the Institute of Medicine recommendations. There was an increased risk for small for gestational age, 3.7% (OR 2.34, 95% CI 1.15-4.76) among women in obesity class III losing weight, but there was no significantly increased risk of small for gestational age in the same group with low weight gain. CONCLUSION: Obese women (class II and III) who lose weight during pregnancy seem to have a decreased or unaffected risk for cesarean delivery, large for gestational age, pre-eclampsia, excessive postpartum bleeding, instrumental delivery, low Apgar score, and fetal distress....
Obes Rev. 2015 Mar;16(3):189-206. doi: 10.1111/obr.12238. Epub 2015 Jan 18. Can we safely recommend gestational weight gain below the 2009 guidelines in obese women? A systematic review and meta-analysis. Kapadia MZ1, Park CK, Beyene J, Giglia L, Maxwell C, McDonald SD. PMID: 25598037
A systematic review was conducted to determine the risk of adverse pregnancy outcomes with gestational weight gain (GWG) below the 2009 Institute of Medicine guidelines compared with within the guidelines in obese women. MEDLINE, Embase, Cochrane Register, CINHAL and Web of Science were searched from 1 January 2009 to 31 July 2014. Quality was assessed using a modified Newcastle-Ottawa scale. Three primary outcomes were included: preterm birth, small for gestational age (SGA) and large for gestational age (LGA). Eighteen cohort studies were included. GWG below the guidelines had higher odds of preterm birth (adjusted odds ratio [AOR] 1.46; 95% confidence interval [CI] 1.07-2.00) and SGA (AOR 1.24; 95% CI 1.13-1.36) and lower odds of LGA (AOR 0.77; 95% CI 0.73-0.81) than GWG within the guidelines. Across the three obesity classes, the odds of SGA and LGA did not show any notable gradient and remained unexplored for preterm birth. Decreased odds were noted for macrosomia (AOR 0.64; 95% CI 0.54-0.77), gestational hypertension (AOR, 0.70; 95% CI 0.53-0.93), pre-eclampsia (AOR 0.90; 95% CI 0.82-0.99) and caesarean (AOR 0.87; 95% CI 0.82-0.92). GWG below the guidelines cannot be routinely recommended but might occasionally be individualized for certain women, with caution, taking into account other known risk factors.
Increased Risks for SGA Infants of Obese Women

J Matern Fetal Neonatal Med. 2016 Jul 22:1-17. [Epub ahead of print] The effects of maternal obesity on perinatal outcomes among those born small for gestational age. Yao R1, Park BY2, Caughey AB3. PMID: 27450769
BACKGROUND:...Small for gestational age (SGA) neonates born to obese women may be associated with pathological growth with increased neonatal complications. METHODS: This was a retrospective cohort study of all non-anomalous singleton neonates born in Texas from 2006-2011. Analyses were limited to births between 34 and 42 weeks gestation with birth weight ≤10th percentile. Results were stratified by maternal pre-pregnancy BMI class. The risk for stillbirth, neonatal death, neonatal intensive care unit (NICU) admission and 5 minute Apgar scores <7 were estimated for each obesity class and compared to the normal weight group. Multivariable logistic regression analyses were performed to control for potential confounding variables. RESULTS: The rate of stillbirth was 1.4/1,000 births for normal weight women, and 2.9/1,000 among obese women (p < 0.001, aOR: 1.83 [1.43, 2.34]). The rate of neonatal deaths among normal weight women was 4.3/1,000 births, whereas among obese women it was 4.7/1,000 (p = 0.94, aOR: 1.10 [0.92, 1.30]). A dose-dependent relationship between maternal obesity and stillbirths was seen, but not for other neonatal outcomes. CONCLUSION: Among SGA neonates, maternal pre-pregnancy obesity was associated with increased risks for stillbirth, NICU admission and low Apgar scores but not neonatal death.
Obstet Gynecol. 2009 Aug;114(2 Pt 1):333-9. doi: 10.1097/AOG.0b013e3181ae9a47. Success of programming fetal growth phenotypes among obese women. Salihu HM1, Mbah AK, Alio AP, Kornosky JL, Bruder K, Belogolovkin V. PMID: 19622995
...METHODS: This was a retrospective cohort study using the Missouri maternally linked cohort files (years 1978-1997)...Fetal growth phenotypes were defined as large for gestational age (LGA), appropriate for gestational age (AGA), and small for gestational age (SGA)...RESULTS:..Neonatal mortality among LGA infants was similar for obese (6.2 in 1,000) and normal (4.9 in 1,000) weight mothers (OR 1.05, 95% confidence interval [CI] 0.75-1.48) and regardless of obesity subtype. By contrast, SGA and AGA infants programmed by obese mothers experienced greater neonatal mortality as compared with those born to normal weight mothers (AGA OR 1.45, 95% CI 1.32-1.59;SGA OR 1.72, 95% CI 1.49-1.98). CONCLUSION: Compared with normal weight mothers, obese women are least successful at programming SGA, less successful at programming AGA, and equally as successful at programming LGA infants.
BJOG. 2016 Feb 8. doi: 10.1111/1471-0528.13896. [Epub ahead of print] Comparison of methods for identifying small-for-gestational-age infants at risk of perinatal mortality among obese mothers: a hospital-based cohort study. Hinkle SN1, Sjaarda LA1, Albert PS2, Mendola P1, Grantz KL1. PMID: 26853429
OBJECTIVE: To assess differences in small-for-gestational age (SGA) classifications for the detection of neonates with increased perinatal mortality risk among obese women and subsequently assess the association between prepregnancy body mass index (BMI) status and SGA. DESIGN: Hospital-based cohort. SETTING: Twelve US clinical centres (2002-08). POPULATION: A total of 114 626 singleton, nonanomalous pregnancies. ...RESULTS: The overall perinatal mortality prevalence was 0.55% and this increased significantly with increasing BMI (P < 0.01)...SGA is less common among obese women but these SGA babies are at a high risk of death and remain an important group for surveillance.

Friday, August 5, 2016

Questionable Claims and Obesity Stigma in Breastfeeding Promotion

Image from the Center for Disease Control
It's World Breastfeeding Week ─ time to highlight the importance of breastfeeding! But not in the way this poster is doing.

I'm all for increasing breastfeeding rates. I've attended La Leche League meetings. I nursed my own four children for several years each. I've promoted breastfeeding on my website and my blog. I've helped other women with breastfeeding issues. It's hard to find a more ardent breastfeeding supporter than me.

However, today I'm going to be a heretic and offer up some criticism of breastfeeding advocacy. In particular, I have concerns with people trying to increase breastfeeding rates by promoting its potential for maternal weight loss or obesity prevention in children.

One press release from 2012 shows a typical example of hyperbole from the U.K.:
Breast-feeding may help mothers reduce the risk of obesity later in life, according to a study of 740,000 post-menopausal women in the U.K. 
For every six months women breast-fed, their body mass index was 0.22, or 1 percent, lower, even decades after giving birth, according to the research
A 1 percent reduction in BMI may seem small, but spread across the population of the U.K., that could mean about 10,000 fewer premature deaths per decade from obesity-related conditions, such as diabetes, heart disease and some cancers,” Valerie Beral, co-author of the study and director of the Cancer Epidemiology Unit at the University of Oxford, said in a statement.
Similarly, many breastfeeding advocates try to raise breastfeeding rates by promoting its potential for obesity prevention in children. The United States Breastfeeding Committee, for example, has a huge campaign promoting breastfeeding as the first step to preventing obesity in children (see graphic from the CDC above). 

These two approaches go unquestioned among many breastfeeding advocates, but they are problematic for several reasons.

First, the evidence is not that strong, and second, public health campaigns using breastfeeding to promote obesity prevention are often highly stigmatizing and full of negative stereotypes. In fact, they may alienate some of the very people they want to reach out to.

A Closer Look at the Evidence

Unfortunately, if you really look at the research, evidence for breastfeeding as obesity prevention in either mother or baby is modest at best.

Maternal Effects

Care providers are concerned about the potential for postpartum weight retention to increase a woman's weight long-term. I understand the concern. Long-term retention of pregnancy weight gain can be a factor in obesity for some women.

But although long-term breastfeeding after birth does result in quicker loss of pregnancy weight for some women, the effect tends to be modest in the research, and not all women find breastfeeding is helpful in postpartum weight loss. A few even find that they don't really lose those final pregnancy pounds until after weaning.

A large research review from the USDA's Center for Nutrition Policy and Promotion (Evidence Analysis Library Division) found:
A moderate body of consistent evidence shows that breastfeeding may be associated with maternal post-partum weight loss. However this weight loss is small, transient, and depends on breastfeeding intensity and duration.
Other meta-analyses have found that the relationship between breastfeeding and post-partum weight retention is very complicated, and definitive proof of benefit is difficult to show.

For maternal weight loss, breastfeeding can be helpful for some women, but in large groups, the effect is not particularly strong.  

The 2012 press release quoted above argues that a 1% reduction in BMI across the board could prevent 10,000 deaths per decade. This is highly speculative. A 1% reduction of BMI is very small and its effects would also probably be small. Their conclusion likely inflates the impact by using questionable data on the relationship between weight and mortality. Note they don't defend their statement or back it up with data; they just make broad, sweeping proclamations about the amount of lives it would save. This is the kind of overreach that is typical of these campaigns.

Furthermore, promoting breastfeeding for weight loss can backfire. A 2011 study found:
Belief that breastfeeding could aid postpartum weight loss was initially high, but unrelated to breastfeeding initiation or intensity. Maintenance of this belief over time, however, was associated with lower lactation scores. BMI was negatively correlated with breastfeeding initiation and intensity. Among overweight and obese women, unrealistic expectations regarding the effect of breastfeeding on weight loss may negatively impact breastfeeding duration.
If you promote breastfeeding as THE way to control weight and then that effect doesn't appear, there is likely to be a backlash. Stop creating unrealistic expectations in women and focus on breastfeeding's other benefits to them.

Effects on Offspring Obesity

Some studies do link breastfeeding with lower obesity rates in children later in life, especially in children at higher risk. While I believe this effect is real to some extent, I have real reservations about touting these studies.

There is more than a tinge of fat-phobia and mother-blaming in the media spin on these studies. The implication is that if you would just breastfeed your baby, it's very unlikely he'll be fat. And that just doesn't match the experience of many people.

Anecdotally, many high-BMI women have breastfed children for a year or more and still have children with weights considered "above normal." Unlike what researchers assume, this is not because we are force-feeding our children junk food or letting them play video games all day. Clearly, there are multiple influences on a child's weight, but genetics is one of the strongest. Breastfeeding does not overcome a strong genetic predisposition to obesity.

Yes, there are some studies that suggest that breastfed babies tend to be less heavy on average, but there are so many other confounding variables in these studies that it's hard to draw definitive conclusions. When other variables are controlled for, not all studies show that breastfeeding is protective against obesity.

For example, a recent large study from the Netherlands shows that breastfeeding did not protect against higher body weight. Although the study did the usual hyperventilating about the "dangers" of pediatric obesity, the authors did acknowledge the weaknesses of promoting breastfeeding for obesity prevention. One of the authors stated:
"It's important not to say things like, 'if you breast-feed your baby, he will not become obese.' " 
This is not the only study that found that breastfeeding was not protective against overweight status. A 2007 study found that having been breastfed as a child did not significantly influence women's adult weight status.

In addition, a randomized controlled trial in Belarus aimed to examine whether increasing breastfeeding rates at the population level prevented pediatric obesity. They succeeded in substantially raising the breastfeeding rates, yet this did not translate into reduced childhood obesity rates. The authors concluded:
Breastfeeding has many advantages but population strategies to increase the duration and exclusivity of breastfeeding are unlikely to curb the obesity epidemic.
This study has been criticized because it increased breastfeeding only modestly and mostly short-term. It still had low long-term breastfeeding rates and did not compare fully formula-fed babies with fully breastfed babies. These are legitimate criticisms. It may be that more differences between the groups would become clear with higher rates of extended breastfeeding and more clear delineations between exclusive formula use and exclusive breastfeeding. Yet the fact that little effect was found despite increased rates is troubling. You would think there would have been some impact.

Another unique study attempted to correct for other variables by looking at siblings within the same family who were fed differently. The strength of this study is that by using siblings in the same family, it corrects for education and socio-economic status and other variables which can strongly influence outcomes. Tellingly, it found virtually no difference in adiposity levels between breastfed and formula-fed siblings.

The majority of the research seems to suggest that while breastfeeding might be somewhat protective against obesity, this effect is small, may not last throughout life, and might be less important than other factors. One very pro-breastfeeding review concluded:
From current available data, any effects of breastfeeding on childhood obesity are likely not large, and tend to be most noted when formula feeding is compared with longer durations of breastfeeding.
The research picture on the effect of breastfeeding on obesity rates is far more muddled than clear. We need to be careful about overstating its effects, and we need to be careful about the language we use when we talk about certain benefits. In particular, its promotion for obesity prevention is questionable. A more accurate description is that breastfeeding may lower the risk for obesity. Although even that is not proven, this phrasing is much more defensible.

From my own review of the research, I believe that breastfeeding probably is associated with a modestly reduced risk of obesity on a population-wide basis, but that most of this effect is due to other variables and probably only short-term. Whatever the impact of exclusive breastfeeding on weight is, it's debatable how important that really is for public health.

Since breastfeeding has many other benefits that are quite clear, it seems more logical to be promoting these, rather than touting breastfeeding as a cure-all for obesity. 

Obesity Bias in Research 

Why might breastfeeding lower the risk for obesity at all? No one knows for sure, but even in the speculations obesity bias rears its ugly head.

The reasoning from the experts is filled with fat-phobic assumptions. For example, experts often imply that bottle-fed babies develop "unnaturally large" appetites because of passive intake vs. breastfed babies' self-regulated intake. This plays into the stereotype that fat kids have little self-control and over-consume food.

Or they state that breastfed babies are more likely to be willing to try new foods like fruits and vegetables. This plays into the stereotype that that obese kids don't eat fruits and vegetables. Because everyone knows that fat kids mostly eat junk food, right?

It's hard to separate researchers' fat-phobic stereotyping from plausible biological mechanisms. The best size-neutral guess is that breastfeeding lowers the risk for insulin resistance among children (which may in turn blunt the risk for diabetes and lower the tendency to gain weight), and it may promote a healthier gut microbiome, which in turn might lead to a lower risk for obesity. That seems quite plausible without relying on obesity stereotypes of over-consumption and poor eating habits.

So there could a biological foundation to the argument that breastfeeding might lower the risk for obesity. But prevent obesity completely? Probably not. There are too many other factors at work. It's far too simplistic to say that breastfeeding protects against obesity.

Furthermore, we need to watch the parent-blaming in these studies. For example, a short-term recent study found that longer breastfeeding was more protective in infants at the most risk for obesity, but that the effect wasn't as strong as hoped. An analysis of the study pointed out that maternal smoking and low education levels were also associated with higher weight, and that there was a lack of information about other feeding behaviors. The implication is that breastfeeding is not enough to overcome bad behavior in the parents. The author concludes:
So, does breastfeeding lower the risk of childhood obesity? My conclusion is yes; but only in infants at higher risk for obesity and [who] are breastfed for longer durations. In addition, as obesity is multifactorial, breastfeeding alone is unlikely to entirely prevent it.
Another author, writing about breastfeeding and childhood obesity, concludes:
The overall consensus is that breastfeeding provides protective factors, but can be mitigated by other factors (i.e. maternal health, environmental, SES, etc.) and should not be considered as an independent factor for obesity prevention.
In other words, those ignorant fat parents can overcome the benefits of breastfeeding by providing an unhealthy home environment and being too uneducated to change their own obesity or develop better health habits. Genetics? Total excuse. Any obesity must be the parents' fault, even if they breastfeed.

Yeah. As a fat parent, that sure makes me want to breastfeed.

Public Health Campaign Stigma

Another problem with promoting breastfeeding to prevent obesity is the biased attitudes these campaigns reinforce and the highly stigmatizing images they use.

(Because formula-feeding your baby is like feeding him candy bars.
And heaven knows that all formula-fed babies are fat and all
breastfed babies are skinny, right?)
Here is an image from a doctor's presentation that basically compares formula use with feeding your baby multiple candy bars a week. The apparent result is a chubby-cheeked sumo baby with multiple fat folds. What, no breastfed baby has ever had chubby cheeks and fat dimples?

And if the figure cited at the bottom is true, surely 30,000 more calories would ensure that all formula-fed babies would be fat and all breastfed ones would be thin. Unless perhaps there are other factors at work too? But heaven forbid those be acknowledged.

Even the articles that admit that a breastfed baby can be at the top of the weight charts usually then blame the baby's weight on the mother's nursing too much and suggest restricting nursing or giving a pacifier. Always a child's weight is blamed on over-consumption and restriction is promoted as the answer. Yet the answers are usually far more complex.

Image from article called
"Breastfeeding is the First Defense Against Obesity"
Here is another image from an article about breastfeeding for preventing obesity. The image has since been taken off of the article, but the fact that it was ever on there in the first place says a great deal about the assumptions and biases of the people promoting these campaigns.

Notice how the little boy (wearing too-small clothes) is gleefully surrounded by cake, ice cream, and lots of candy. Articles like this often use troubling images that strongly reinforce stereotypes about obesity and which likely increase obesity stigma and discrimination.

The image used for a blog post about preventing obesity
through breastfeeding, written by a lactation consultant (IBCLC)
Here's another image from a similar article ─ written by an influential professional lactation consultant, no less! Notice the too-small shirt, the hanging belly, and the prominent sweets (not one but TWO ice cream cones). Because you know that all obese children are that way because they are gorging on sweets and stuffing themselves to the max.

Here is an image from an article about a U.S. breastfeeding promotion campaign. It has the image of a breastfeeding woman of size, which is so rare that it should be a positive thing ─ but it's not. How typical that one of the very few images you can find of a woman of size breastfeeding is from a campaign that assumes that the diet of a high-BMI woman couldn't possibly be normal or healthy. The fact that the woman of size is also a woman of color makes it even more stigmatizing.

As a fat mother, I can tell you that these kinds of ads and articles make me want to breastfeed less, not more. In fact, they piss me off no end.

My Experience

In defiance of images like these, I breastfed my four kids for about 2.5 to 4 years each. That's a cumulative total of somewhere around 10 years. So if anyone should have seen a reduction in maternal BMI due to breastfeeding, it should have been me! Yet I didn't. I know many other women of size who also had a similar experience.

But surely all that breastfeeding reduced obesity in my children, right? I did all the "right" things. Not only was each child breastfed for multiple years (not months), I don't smoke, I am highly educated, I had a very small weight gain in pregnancy, we are in a higher socio-economic group, I didn't work outside the home for years, and I didn't introduce solids before 6 months. According to the research, they should be close to average-sized, right?

Nope. My first three children have a BMI near the top of the Class I obesity range, about where I was at their ages. I'm sure that critics will blame me by claiming that an obesogenic environment trumps everything (no doubt believing I force-fed them chocolate-covered french fries), but really, we did a great deal to promote healthy eating and exercise. Their habits were better than many of the children around them, but they were still fat.

On the other hand, my fourth child is skinny as the day is long, despite eating the same food and having the same genetic background as the rest of the kids. She didn't breastfeed longer or exercise more than the others; she simply seems to have benefited from a lucky throw of the genetics dice. She just took after a different branch of the family tree, apparently.

Same parents, same gene pool, same food, same environment, similar basic breastfeeding period ─ yet they have far different outcomes. Sure, that's only one family's experience, but I think it demonstrates that there are no simple answers here. And that's what I object to ─ the simplistic and stigmatizing messages that experts are putting out about breastfeeding and obesity.


Breastfeeding is amazing. So many health benefits come along with breastfeeding! It has a lot of short-term benefits in lowering the risk for illness in young children. It has a lot of long-term benefits in terms of metabolic improvements, lower risk for breast cancer, ovarian cancer, diabetes, heart disease etc. in mothers.

In this country (and many others), far too few babies are breastfed. Even among those whose mothers do nurse, breastfeeding last only a few months, instead of the years it was biologically designed for. The public health implications from such low rates of breastfeeding are perfectly valid topics for discussion.

But when breastfeeding is promoted as a well-intentioned but biased bludgeon to "prevent" obesity, I start getting cranky. I've held my tongue about it for too long. It's time to call out the breastfeeding advocates who distort the science and promote obesity stigma in trying to increase breastfeeding rates.

Look at the following breastfeeding advocacy poster.

Lowering the risk of obesity is the top benefit listed. Really? If there is an effect on obesity, it's quite small. Frankly, other benefits are FAR more important. (At least the poster does use the phrase, "lowers the risk for." That's something. Too many campaigns are using words like "prevent" or "protect from" obesity.)

Let's be clear about what needs to change in breastfeeding advocacy:

  1. Breastfeeding campaigns need to stop overstating the evidence. The research shows that breastfeeding is unlikely to prevent obesity. We can mention that it might lower the risk somewhat, but even then most of the difference is attributable to other variables
  2. We need to de-emphasize weight loss or obesity prevention as motivations in breastfeeding advocacy materials. Focus instead on other benefits that are far more clear and evidence-based
  3. We need to be very careful about the language and images we use to discuss weight and breastfeeding. We need to eliminate the assumptions and stereotyping about obesity in breastfeeding research and drop the stigmatizing images used in breastfeeding campaigns
I'm ALL for promoting breastfeeding, but the truth is that weight is complex. A lot of fat women breastfeed and never lose weight, and a lot of fat women breastfeed for years and still have fat children. There are also plenty of formula-fed children who are thin. Breastfeeding is just not the weight cure-all that authorities want it to be and we need to stop telling people that it is. 

Stop using "obesity prevention" as a way to promote breastfeeding. Focus on the MANY other benefits which are far more clear in the research. And stop playing on societal fears and obesity stigma in breastfeeding advocacy materials.