Breastfeeding Lowers the Risk for High Blood Pressure and Other Problems in Mid-Life

Photo credit: La Leche League

A new study indicates that breastfeeding can lower the risk for hypertension in middle-aged African-American women.

Interestingly, the study did not find much protection against EVER getting high blood pressure, but it did find a modest protective effect of breastfeeding on getting high blood pressure in your 40s. In other words, it had a temporary but important protective effect as women approached menopause, when high blood pressure often develops. In addition, the longer the duration of breastfeeding, the more protection there was.

This seems to echo other studies in other groups that have found similar protective effects against blood pressure issues in early middle age (the 40s) but not as much difference in older ages (after 65 or so).

It's disappointing that breastfeeding doesn't have the long-term, permanent effect everybody hoped for, but even so, this delay in development of high blood pressure is very important because the longer you have high blood pressure, the more complications like heart disease or kidney disease develop. Even just delaying it can reduce the cumulative disease burden on the body.

Breastfeeding can hopefully help people minimize their risk for these diseases. This is especially important for African-Americans, who are particularly susceptible to early onset of hypertension and cardiovascular issues.

More support  is needed in helping African-American women initiate and breastfeed long-term because it could make a critical difference in their health, as well as their babies' health. Here are some resources that might be helpful:

• Black Women Do Breastfeed Facebook Page and Website
• African American Breastfeeding Network
• Lactation Support Groups for Families of Color
• Black Mothers Breastfeeding Association
• Planning Ahead
• National Association of Professional and Peer Lactation Supporters of Color

And here are some general breastfeeding resources:

• KellyMom.com: Breastfeeding and Parenting - Evidence-based answers to breastfeeding questions
• Newman Breastfeeding Clinic and Institute - Breastfeeding resources and videos
• La Leche League- Breastfeeding resources and mother support groups
• Infant Risk Center- Information on use of medications while breastfeeding
• Womenshealth.gov- Information and support to help women breastfeed successfully
• Work and Pump - Support and information for working mothers
• International Lactation Consultant Association - Find a lactation consultant
• LactMed - Database of information on drugs and potential effects on nursing babies

Implications Beyond Hypertension 

Photo Credit: Center for Disease Control

Breastfeeding has important lifelong benefits beyond the obvious immediate benefits to the baby.

One of these is the delay of development of hypertension in the mother. Research also shows the breastfeeding, especially long-term breastfeeding, helps prevent or delay diabetes and heart problems, and lowers the incidence of cardiovascular mortality (see studies in References below).

Biologically speaking, women evolved to have children and then breastfeed them for extended periods of time. When women have children but don't breastfeed (or breastfeed only briefly), there is inadvertent metabolic fallout. As one study summarizes:

Researchers hypothesize that pregnancy and lactation are part of a continuum, with lactation meant to "reset" the adverse metabolic profile that develops as a part of normal pregnancy, and that when lactation does not occur, women maintain an elevated risk of cardio-metabolic diseases.

This is not to shame or scold women who don't or can't breastfeed long-term. Not every woman can breastfeed fully, some women's situations prevent breastfeeding for long, and of course it's always up to the woman to decide how she will feed her baby.

But from an evolutionary point of view, breastfeeding, especially long-term breastfeeding, keeps women healthier longer. 

We need to do everything we can to help support breastfeeding women, and especially breastfeeding women of color.


References

Breastfeeding and Hypertension

Am J Epidemiol. 2017 Oct 15;186(8):927-934. doi: 10.1093/aje/kwx163. Cumulative Lactation and Onset of Hypertension in African-American Women. Chetwynd EM, Stuebe AM, Rosenberg L, Troester M, Rowley D, Palmer JR. PMID: 28535171

Hypertension affects nearly 1 of 3 women and contributes to cardiovascular disease, the leading cause of death in the United States. Breastfeeding leads to metabolic changes that could reduce risks of hypertension. Hypertension disproportionately affects black women, but rates of breastfeeding among black women lag behind those in the general population. In the Black Women's Health Study (n = 59,001), we conducted a nested case-control analysis using unconditional logistic regression to estimate the association between breastfeeding and incident hypertension at ages 40-65 years using data collected from 1995 to 2011... Overall, there was little evidence of association between ever breastfeeding and incident hypertension (odds ratio = 0.97, 95% confidence interval: 0.92, 1.02). However, age modified the relationship (P = 0.02): Breastfeeding was associated with reduced risk of hypertension at ages 40-49 years (odds ratio = 0.92, 95% confidence interval: 0.85, 0.99) but not at older ages. In addition, risk of hypertension at ages 40-49 years decreased with increasing duration of breastfeeding (P for trend = 0.08). Our results suggest that long-duration breastfeeding may reduce the risk of incident hypertension in middle age. Addressing breastfeeding as a potential preventative health behavior is particularly compelling because it is required for only a discrete period of time.

Am J Obstet Gynecol. 2013 Jun;208(6):454.e1-7. doi: 10.1016/j.ajog.2013.02.014. Epub 2013 Feb 7. Association between parity and breastfeeding with maternal high blood pressure. Lupton SJ, Chiu CL, Lujic S, Hennessy A, Lind JM. PMID: 23395924

...Baseline data for 74,785 women were sourced from the 45 and Up Study, Australia. These women were 45 years of age or older, had an intact uterus, and had not been diagnosed with high blood pressure before pregnancy...The combination of parity and breastfeeding was associated with lower odds of having high blood pressure (adjusted OR, 0.89; 99% CI, 0.82-0.97; P < .001), compared with nulliparous women...Women who breastfed for longer than 6 months in their lifetime, or greater than 3 months per child, on average, had significantly lower odds of having high blood pressure when compared with parous women who never breastfed. The odds were lower with longer breastfeeding durations and were no longer significant in the majority of women over the age of 64 years....

Breastfeed Med. 2015 Apr;10(3):163-7. doi: 10.1089/bfm.2014.0116. Epub 2015 Mar 18. Breastfeeding and maternal hypertension and diabetes: a population-based cross-sectional study. Zhang BZ, Zhang HY, Liu HH, Li HJ, Wang JS. PMID: 25785993

...A cross-sectional study was conducted in four urban communities of Beijing, China, with 9,128 parous women 40-81 years of age who had had only one lifetime birth...After the analysis was adjusted for the potential confounders...the odd ratio (OR) of hypertension was 1.18 (95% confidence interval [CI], 1.05-1.32) for women who did not breastfeed, compared with women who did. In addition, the ORs for >0 to 6 months, >6 to 12 months, and >12 months of breastfeeding were 0.87 (95% CI, 0.76-0.99), 0.83 (95% CI, 0.68-1.00), and 0.79 (95% CI, 0.65-0.97), respectively, compared with women who did not breastfeed. With adjustment for age, WHR, working status, educational level, family history of diabetes, and postpartum BMI, women who did not breastfeed increased the risk of diabetes (OR=1.30; 95% CI, 1.11-1.53) compared with women who did. Moreover, women who breastfed for >0 to 6 months (OR=0.81; 95% CI, 0.67-0.98) and >6 to 12 months (OR=0.46; 95% CI, 0.26-0.84) had a lower risk of diabetes, compared with women who did not breastfeed. CONCLUSIONS: Chinese mothers who did not breastfeed were more likely to develop hypertension and diabetes in later life.

Am J Epidemiol. 2011 Nov 15;174(10):1147-58. doi: 10.1093/aje/kwr227. Epub 2011 Oct 12. Duration of lactation and incidence of maternal hypertension: a longitudinal cohort study. Stuebe AM, Schwarz EB, Grewen K, Rich-Edwards JW, Michels KB, Foster EM, Curhan G, Forman J. PMID: 21997568

Never or curtailed lactation has been associated with an increased risk for incident hypertension, but the effect of exclusive breastfeeding is unknown. The authors conducted an observational cohort study of 55,636 parous women in the US Nurses' Health Study II... In conclusion, never or curtailed lactation was associated with an increased risk of incident maternal hypertension, compared with the recommended ≥6 months of exclusive or ≥12 months of total lactation per child, in a large cohort of parous women.

Breastfeeding and Diabetes

Obstet Gynecol. 2016 Nov;128(5):1095-1104. Breastfeeding Initiation Associated With Reduced Incidence of Diabetes in Mothers and Offspring. Martens PJ, Shafer LA, Dean HJ, Sellers EA, Yamamoto J, Ludwig S, Heaman M, Phillips-Beck W, Prior HJ, Morris M, McGavock J, Dart AB, Shen GX. PMID: 27741196

This retrospective database study included 334,553 deliveries (1987-2011) in Manitoba with up to 24 years of follow-up for diabetes using population-based databases... RESULTS: Breastfeeding initiation was recorded in 83% of non-First Nations mothers and 56% of First Nations mothers (P<.001)... With 24 years of follow-up or less, breastfeeding initiation was associated with a 17% lower risk of youth-onset type 2 diabetes in offspring (HR 0.83, CI 0.69-0.99, P=.038)... CONCLUSION: Breastfeeding initiation is associated with a reduced risk of diabetes among women and their offspring in Manitoba. The results suggest that breastfeeding might be a potentially modifiable factor to reduce the risk of diabetes in both First Nations and non-First Nations women and children.

Diabetes Care. 2010 Jun;33(6):1239-41. doi: 10.2337/dc10-0347. Epub 2010 Mar 23. Parity, breastfeeding, and the subsequent risk of maternal type 2 diabetes. Liu B, Jorm L, Banks E. PMID: 20332359

...Using information on parity, breastfeeding, and diabetes collected from 52,731 women recruited into a cohort study, we estimated the risk of type 2 diabetes using multivariate logistic regression... Among parous women, there was a 14% (95% CI 10-18%, P < 0.001) reduced likelihood of diabetes per year of breastfeeding... CONCLUSIONS: Compared with nulliparous women, childbearing women who do not breastfeed have about a 50% increased risk of type 2 diabetes in later life. Breastfeeding substantially reduces this excess risk.

JAMA. 2005 Nov 23;294(20):2601-10. Duration of lactation and incidence of type 2 diabetes. Stuebe AM1, Rich-Edwards JW, Willett WC, Manson JE, Michels KB. PMID: 16304074

...Prospective observational cohort study of 83,585 parous women in the Nurses' Health Study (NHS) and retrospective observational cohort study of 73,418 parous women in the Nurses' Health Study II (NHS II)...RESULTS: ...Among parous women, increasing duration of lactation was associated with a reduced risk of type 2 diabetes. For each additional year of lactation, women with a birth in the prior 15 years had a decrease in the risk of diabetes of 15% (95% confidence interval, 1%-27%) among NHS participants and of 14% (95% confidence interval, 7%-21%) among NHS II participants, controlling for current body mass index and other relevant risk factors for type 2 diabetes. CONCLUSIONS: Longer duration of breastfeeding was associated with reduced incidence of type 2 diabetes in 2 large US cohorts of women....

Diabetologia. 2008 Feb;51(2):258-66. Epub 2007 Nov 27. Duration of breast-feeding and the incidence of type 2 diabetes mellitus in the Shanghai Women's Health Study. Villegas R1, Gao YT, Yang G, Li HL, Elasy T, Zheng W, Shu XO. PMID: 18040660

...This was a prospective study of 62,095 middle-aged parous women in Shanghai, China, who had no prior history of type 2 diabetes mellitus, cancer or cardiovascular disease at study recruitment... RESULTS: Women who had breastfed their children tended to have a lower risk of diabetes mellitus than those who had never breastfed [relative risk (RR)=0.88; 95% CI, 0.76-1.02; p=0.08]. Increasing duration of breast-feeding was associated with a reduced risk of type 2 diabetes mellitus. The fully adjusted RRs for lifetime breast-feeding duration were 1.00, 0.88, 0.89, 0.88, 0.75 and 0.68 (p trend=0.01) for 0, >0 to 0.99, >0.99 to 1.99, >1.99 to 2.99, >2.99 to 3.99 and >or=4 years in analyses adjusted for age, daily energy intake, BMI, WHR, smoking, alcohol intake, physical activity, occupation, income level, education level, number of live births and presence of hypertension at baselines....

Breastfeeding and Cardiovascular Health/Mortality

Annu Rev Nutr. 2016 Jul 17;36:627-45. doi: 10.1146/annurev-nutr-071715-051213. Epub 2016 May 4. Lactation and Maternal Cardio-Metabolic Health. Perrine CG, Nelson JM, Corbelli J, Scanlon KS. PMID: 27146017

Researchers hypothesize that pregnancy and lactation are part of a continuum, with lactation meant to "reset" the adverse metabolic profile that develops as a part of normal pregnancy, and that when lactation does not occur, women maintain an elevated risk of cardio-metabolic diseases. Several large prospective and retrospective studies, mostly from the United States and other industrialized countries, have examined the associations between lactation and cardio-metabolic outcomes. Less evidence exists regarding an association of lactation with maternal postpartum weight status and dyslipidemia, whereas more evidence exists for an association with diabetes, hypertension, and subclinical and clinical cardiovascular disease.

Am J Obstet Gynecol. 2009 Feb;200(2):138.e1-8. doi: 10.1016/j.ajog.2008.10.001. Epub 2008 Dec 25. Duration of lactation and incidence of myocardial infarction in middle to late adulthood. Stuebe AM, Michels KB, Willett WC, Manson JE, Rexrode K, Rich-Edwards JW. PMID: 19110223

We assessed the relation between duration of lactation and maternal incident myocardial infarction. STUDY DESIGN: This was a prospective cohort study of 89,326 parous women in the Nurses' Health Study. RESULTS:... Compared with parous women who had never breastfed, women who had breastfed for a lifetime total of 2 years or longer had 37% lower risk of coronary heart disease (95% confidence interval, 23-49%; P for trend < .001), adjusting for age, parity, and stillbirth history. With additional adjustment for early-adult adiposity, parental history, and lifestyle factors, women who had breastfed for a lifetime total of 2 years or longer had a 23% lower risk of coronary heart disease (95% confidence interval, 6-38%; P for trend = .02) than women who had never breastfed. CONCLUSION: In a large, prospective cohort, long duration of lactation was associated with a reduced risk of coronary heart disease.

BMC Public Health. 2013 Nov 13;13:1070. doi: 10.1186/1471-2458-13-1070. A prospective population-based cohort study of lactation and cardiovascular disease mortality: the HUNT study. Natland Fagerhaug T, Forsmo S, Jacobsen GW, Midthjell K, Andersen LF, Ivar Lund Nilsen T. PMID: 24219620

...In a Norwegian population-based prospective cohort study, we studied the association of lifetime duration of lactation with cardiovascular mortality in 21,889 women aged 30 to 85 years who attended the second Nord-Trøndelag Health Survey (HUNT2) in 1995-1997. The cohort was followed for mortality through 2010 by a linkage with the Cause of Death Registry...RESULTS:...Parous women younger than 65 years who had never lactated had a higher cardiovascular mortality than the reference group of women who had lactated 24 months or more (HR 2.77, 95% confidence interval [CI]: 1.28, 5.99)...CONCLUSIONS: Excess cardiovascular mortality rates were observed among parous women younger than 65 years who had never lactated. These findings support the hypothesis that lactation may have long-term influences on maternal cardiovascular health.

Low Prenatal Weight Gain Does Not Prevent Blood Pressure Issues in "Obese" Women

One idea often promoted by care providers is that keeping prenatal weight gains to the minimum possible or losing weight in pregnancy will prevent blood pressure issues (Gestational Hypertension or Pre-Eclampsia) in "obese" women.

One of the most dreaded complications of pregnancy is blood pressure issues like GHTN and PE, and obese women really are at increased risk for these complications. It is understandable that care providers want to try to prevent that if at all possible.

However, here is a recent study that shows that losing weight and very low gains in pregnancy did not lower the rate of Gestational Hypertention (GHTN) or Pre-Eclampsia (PE) in obese women.

This is important because, as we have discussed before, more and more providers are zeroing in on weight gain in pregnancy as a way to try and prevent complications in higher weight women.

There have been studies which found that lower weight gains were correlated with lower rates of pre-eclampsia, and higher gains with higher rates of pre-eclampsia. However, this doesn't mean that deliberately restricting weight gain prevents PE. As Nohr 2008 states:

Any causal interpretation of the association between total weight gain and these complications is limited. For preeclampsia, high total gain most likely reflects pathologic fluid retention as part of the disease.

In other words, just because very low gain is associated with less pre-eclampsia, it does not follow that making women gain very little weight during pregnancy will prevent pre-eclampsia. Instead, higher weight gain is usually simply a side effect of pre-eclampsia due to the fluid retention and swelling common to pre-eclampsia.

Despite this, many caregivers imply that women can prevent pre-eclampsia by controlling their weight gain during pregnancy. Some are resorting to "scorched earth" tactics, including some truly frightening and extreme nutritional advice, or by encouraging women to lose weight during pregnancy.

This latest study shows that blood pressure issues in pregnancy can't be reliably prevented by having obese women gain minimally or even by losing weight while pregnant. 

Care providers should not be putting higher-weight women on extreme restrictions while pregnant, nor should they be expecting them to lose weight.

Too many care providers see weight gain within recommended limits as a surrogate marker of a woman's nutrition and exercise habits. Women can gain "appropriately" and still have terrible nutrition, and women can gain above or below the recommended limits and still have great nutrition and habits. Discussions about weight gain in pregnancy need to move beyond the scale.

While it's perfectly appropriate to inform higher-weight women of the most optimal prenatal weight gain range to shoot for and to give them reasonable counseling about how to do so, it's much more important to emphasize great nutrition and regular exercise. Then trust the woman's body to gain what it needs to gain for that pregnancy.


Reference

Am J Perinatol. 2014 Dec 8. [Epub ahead of print] The Influence of Gestational Weight Gain on the Development of Gestational Hypertension in Obese Women. Barton JR, Joy SD, Rhea DJ, Sibai AJ, Sibai BM. PMID: 25486285

OBJECTIVE: The objective of this study was to examine the influence of gestational weight gain on the development of gestational hypertension/preeclampsia (GHTN/PE) in women with an obese prepregnancy body mass index (BMI). 

METHODS: Obese women with a singleton pregnancy enrolled at < 20 weeks were studied. Data were classified according to reported gestational weight gain (losing weight, under-gaining, within target, and over-gaining) from the recommended range of 11 to 9.7 kg and by obesity class (class 1 = BMI 30-34.9 kg/m2, class 2 = 35-39.9 kg/m2, class 3 = 40-49.9 kg/m2, and class 4 ≥ 50 kg/m2). Rates of GHTN/PE were compared by weight gain group overall and within obesity class using Pearson chi-square statistics. 

RESULTS: For the 27,898 obese women studied, rates of GHTN/PE increased with increasing class of obesity (15.2% for class 1 and 32.0% for class 4). The incidence of GHTN/PE in obese women was not modified with weight loss or weight gain below recommended levels. Overall for obese women, over-gaining weight was associated with higher rates of GHTN/PE compared with those with a target rate for obesity classes 1 to 3 (each p < 0.001). 

CONCLUSION: Below recommended gestational weight gain did not reduce the risk for GHTN/PE in women with an obese prepregnancy BMI. These data support a gestational weight gain goal ≤ 9.7 kg in obese gravidas.

PCOS Series: A Return

It's time to continue our series on PCOS, Polycystic Ovarian Syndrome.

For those not familiar with it, PCOS is an endocrine condition that affects many women of size (and some women of average size). Between 5-10% of women are thought to have this condition, but  many women go undiagnosed or undertreated.

Symptoms often include irregular or missing periods; hirsutism (excess body hair); significant weight gain and difficulty losing weight; cystic acne; alopecia (thinning hair on the scalp); acanthosis nigricans (dark patches of skin on the thighs, arms, breasts, or neck); and insulin resistance.

However, you don't have to have all of these symptoms to have PCOS, and the condition can present in many different ways. You can take a survey of possible symptoms here.

PCOS is often accompanied by other conditions like hypothyroidism, diabetes, high blood pressure, and many others.  Although many people focus mainly on its effect on childbearing and appearance, PCOS can have life-long health implications.  Therefore, treating it is critical, even if you don't want children or don't care about its cosmetic effects.

A while ago, we started a periodic series about PCOS. We talked about its definition and symptoms, how it presents, its testing and diagnosis, and its possible causes.

If you have not yet read these blog posts, I urge you to do so.  Even if you don't have PCOS, it's important for more people to learn about this condition, how it presents, and its many health implications.

Now it's time to expand the PCOS series with new installments.  This time, let's talk about treatment choices for PCOS.

We're going to do an overview of treatment options for PCOS, and then discuss treatment for the metabolic issues of PCOS and treatment for the cosmetic challenges of PCOS.

Future projected installments will address other aspects of PCOS, such as treatment for fertility concerns, potential pregnancy challenges with PCOS, potential breastfeeding challenges with PCOS, and the impact of PCOS on menopause. But let's focus on treatment of metabolic and cosmetic challenges first.

Why A Series About PCOS Here?

For a long time, I didn't write much about PCOS on my blog or website because there are plenty of other resources on the internet with PCOS information, and I saw no need to duplicate what was already out there.

However, I came back to writing about the topic here because most PCOS websites have a tremendous weight-loss emphasis, leading many fat-acceptance folk to avoid these sites and miss important information about the condition. I wanted to present good, in-depth information without pushing weight loss, something that is very missing in most PCOS resources.

Of course, this is going to displease the weight loss devotees in PCOS circles...both consumers and doctors. The weight-centric paradigm runs very strong in PCOS circles, both in medical research and consumer-based resources. Even the mere suggestion that dieting may be counter-productive is absolute heresy there.

To those folks, I say....Everyone is their own boss. If you wish, you can certainly pursue weight loss as a possible treatment for your PCOS; no one here is going to stop you.  Certainly, there is some research that weight loss can be helpful for PCOS, at least temporarily.  If you want to pursue that, go ahead. There are plenty of PCOS resources out there friendly to that approach.

The problem is that this research, like most research on weight loss, is short in duration, doesn't show long-term outcomes, and completely ignores the risks that can be associated with weight loss.  Does weight loss really benefit your health if you end up heavier afterwards and with more eating-disordered behaviors?  Or if you end up with gallstones or kidney cancer from weight cycling?

Given the overwhelming evidence of poor long-term success with weight loss and the significant harms that can come from yo-yo dieting, it's important to know that there is an alternative, that you can treat your PCOS without having to resort to yet another diet that is likely to fail. This series will not ignore the possibility of weight loss as treatment, but promoting weight loss will not be its focus, unlike 99% of the other PCOS resources out there.  It's vital that we have a resource like this so that folks with PCOS know there is an alternative.

As with any medical situation, readers will have to carefully consider the pros and cons of all their choices and decide what is right for themselves, whether that involves intentional weight loss or stepping into a Health At Every Size® paradigm instead. Whatever you decide for you is fine; just make that decision from an informed place.

But this series is intended to point out that there are treatment approaches that can help mitigate the risks of PCOS without emphasizing weight loss.  

TRIGGER WARNING: If you are a person who would find any mention of weight loss offensive or triggering, you might want to be cautious about the upcoming posts on PCOS Treatments.  Although these PCOS posts will not promote weight loss (most won't even discuss it), a few will mention it as one of the common treatments recommended and why. Those posts that do mention weight loss will have a Trigger Warning clearly posted near the beginning so those who want to avoid any weight loss discussion can do so. 

You should also be very cautious about reading the research summaries and links in all of the PCOS references; these are from traditional PCOS resources, and therefore are full of weight loss promotion.  I include them because I feel it is important to always include reference citations in articles that deal with medical issues, and I include abstracts (or portions of abstracts) so that consumers can quickly scan a summary of the research and vet these arguments for themselves.

It's never my intention to promote dieting in any way, but it's difficult to discuss PCOS adequately without at least passing mention of weight loss issues and posting the relevant references. I've discussed this with the fatosphere monitors and they approved this approach. This advance notification and trigger warnings in any post that touches on weight loss was their suggested way to manage any concerns.

Postscript

At some point, I'd also love to share some stories from PCOS women who follow a Health At Every Size® model. I'd like to see stories on how they manage their condition without a weight-loss emphasis, and how they manage their dealings with weight-centric medical authorities in a proactive and positive way.

If you'd like to share your story, please email me at kmom AT plus-size-pregnancy DOT  org to share your story. Be sure to give me permission to share your story, and let me know how you want it identified (pseudonyms or first names are fine; I strongly discourage use of full names).  Brevity is very important; just give a quick summary of how you manage PCOS without a weight-loss emphasis and why you do so. I reserve the right to edit submissions and to use the submission as needed. After the next series of PCOS posts (and when I have enough entries), I will publish a blog post sharing these stories.

References

Int J Obes Relat Metab Disord. 2000 Sep;24(9):1107-10. Can anyone successfully control their weight? Findings of a three year community-based study of men and women. Crawford D, Jeffery RW, French SA.   PMID: 11033978

This study examined the prevalence, distribution and correlates of successful weight loss and successful weight maintenance over three years in a community-based sample of 854 subjects aged 20-45 at baseline. More than half (53.7%) of the participants in the study gained weight within the first twelve months, only one in four (24.5%) successfully avoided weight gain over three years, and less than one in twenty (4.6%) lost and maintained weight successfully. The findings underscore the importance of current public health efforts to prevent weight gain, and suggest that without much greater efforts to promote and support weight control the prevalence of obesity will continue to rise.

Am Psychol. 2007 Apr;62(3):220-33. Medicare's search for effective obesity treatments: diets are not the answer. Mann T, Tomiyama AJ, Westling E, Lew AM, Samuels B, Chatman J. PMID: 17469900

The prevalence of obesity and its associated health problems have increased sharply in the past 2 decades. New revisions to Medicare policy will allow funding for obesity treatments of proven efficacy. The authors review studies of the long-term outcomes of calorie-restricting diets to assess whether dieting is an effective treatment for obesity. These studies show that one third to two thirds of dieters regain more weight than they lost on their diets, and these studies likely underestimate the extent to which dieting is counterproductive because of several methodological problems, all of which bias the studies toward showing successful weight loss maintenance. In addition, the studies do not provide consistent evidence that dieting results in significant health improvements, regardless of weight change. In sum, there is little support for the notion that diets lead to lasting weight loss or health benefits.

J Am Diet Assoc. 1996 Jun;96(6):589-92; quiz 593-4. Psychological consequences of food restriction. Polivy J.  PMID: 8655907

A review of the literature and research on food restriction indicates that inhibiting food intake has consequences that may not have been anticipated by those attempting such restriction. Starvation and self-imposed dieting appear to result in eating binges once food is available and in psychological manifestations such as preoccupation with food and eating, increased emotional responsiveness and dysphoria, and distractibility. Caution is thus advisable in counseling clients to restrict their eating and diet to lose weight, as the negative sequelae may outweigh the benefits of restraining one's eating. Instead, healthful, balanced eating without specific food restrictions should be recommended as a long-term strategy to avoid the perils of restrictive dieting.

J Am Diet Assoc. 2007 Mar;107(3):448-55. Why does dieting predict weight gain in adolescents? Findings from project EAT-II: a 5-year longitudinal study. Neumark-Sztainer D, Wall M, Haines J, Story M, Eisenberg ME.   PMID: 17324664 

OBJECTIVE: Dieting has been found to predict weight gain in adolescents, but reasons for this association remain unclear. This study aimed to explore potential mechanisms by which dieting predicts weight gain over time in adolescents. DESIGN: Population-based, 5-year longitudinal study. PARTICIPANTS: Adolescents (n=2,516) from diverse ethnic and socioeconomic backgrounds who completed Project EAT (Eating Among Teens) surveys in 1999 (Time 1) and 2004 (Time 2). MAIN OUTCOME MEASURE: Body mass index (BMI) change over 5 years. STATISTICAL ANALYSIS: Multiple regressions were used to examine associations between Time 1 dieting and Time 2 binge eating, breakfast consumption, fruit and vegetable intake, and physical activity. Associations were then examined between these behaviors and BMI change. Finally, to test for mediating effects, associations between dieting and BMI change were examined with and without the inclusion of these behaviors, and regression coefficients were compared. RESULTS: In female adolescents, dieting predicted increased binge eating (P<0.001) and decreased breakfast consumption (P=0.030). In male adolescents, dieting predicted increased binge eating (P<0.001), decreased physical activity (P=0.006), and a trend toward decreased breakfast consumption (P=0.064). These behaviors were also associated with increases in BMI. The association between dieting and BMI increase was weakened, but still remained significant, after binge eating, breakfast consumption, fruit/vegetable intake, and physical activity were included in the model being tested. Thus, the longitudinal association between dieting and BMI increase was partially mediated by these behaviors. CONCLUSIONS: In part, dieting may lead to weight gain via the long-term adoption of behavioral patterns that are counterproductive to weight management.

Am J Epidemiol. 2007 Oct 1;166(7):752-9. Epub 2007 Jul 5. Body size, weight cycling, and risk of renal cell carcinoma among postmenopausal women: the Women's Health Initiative (United States). Luo J, Margolis KL, Adami HO, Lopez AM, Lessin L, Ye W; Women's Health Initiative Investigators. PMID: 17615089

Although obesity is an established risk factor for renal cell carcinoma, the possible effect of central adiposity and long-term variation in weight has yet to be established. The authors studied 140,057 women aged 50-79 years enrolled in the Women's Health Initiative in the United States to examine the role of obesity, especially abdominal obesity, and weight cycling in relation to risk of renal cell carcinoma among postmenopausal women. Cox models were used to estimate relative risks and their corresponding 95% confidence intervals. During an average of 7.7 years of follow-up through September 12, 2005, a total of 269 incident cases of renal cell carcinoma were identified. Central adiposity, as indicated by waist-to-hip ratio, was an important risk factor for developing renal cell carcinoma (highest vs. lowest quartile: relative risk = 1.8, 95% confidence interval: 1.2, 2.5; p for trend = 0.0003). Moreover, women who had experienced weight cycling more than 10 times were at 2.6 times (95% confidence interval: 1.6, 4.2) increased risk compared with women whose weight was stable. Results add evidence that obesity, particularly central adiposity, is associated with an increased risk of renal cell carcinoma among postmenopausal women. Furthermore, they indicate that weight cycling is independently associated with further increased risk of this malignancy.

Ann Intern Med. 1999 Mar 16;130(6):471-7. Long-term weight patterns and risk for cholecystectomy in women. Syngal S, Coakley EH, Willett WC, Byers T, Williamson DF, Colditz GA. PMID: 10075614

BACKGROUND: Obesity and rapid weight loss in obese persons are known risk factors for gallstones. However, the effect of intentional, long-term, moderate weight changes on the risk for gallstones is unclear...SETTING: 11 U.S. states. PARTICIPANTS: 47,153 female registered nurses who did not undergo cholecystectomy before 1988...RESULTS: During the exposure period (1972 to 1988), there was evidence of substantial variation in weight due to intentional weight loss during adulthood. Among cohort patients, 54.9% reported weight cycling with at least one episode of intentional weight loss associated with regain. Of the total cohort, 20.1% were light cyclers (5 to 9 lb of weight loss and gain), 18.8% were moderate cyclers (10 to 19 lb of weight loss and gain), and 16.0% were severe cyclers (> or = 20 lb of weight loss and gain). Net weight gain without cycling occurred in 29.3% of women; net weight loss without cycling was the least common pattern (4.6%). Only 11.1% of the cohort maintained weight within 5 lb over the 16-year period. In the study, 1751 women had undergone cholecystectomy between 1988 and 1994. Compared with weight maintainers, the relative risk for cholecystectomy (adjusted for body mass index, age, alcohol intake, fat intake, and smoking) was 1.20 (95% CI, 0.96 to 1.50) among light cyclers, 1.31 among moderate cyclers (CI, 1.05 to 1.64), and 1.68 among severe cyclers (CI, 1.34 to 2.10). CONCLUSION: Weight cycling was highly prevalent in this large cohort of middle-aged women. The risk for cholecystectomy associated with weight cycling was substantial, independent of attained relative body weight.

BMI and Blood Pressure Measurement in Pregnancy

BP Cuff Size Chart
(exact cutoffs may vary by brand)

We've written before about the importance of using a large cuff for blood pressure measurement in women of size.

Yet sometimes using a large BP cuff for women of size is not done routinely, especially in obstetrics.  

Here's yet another study documenting the importance of the correct cuff size in "obese" women in pregnancy.  

Note that Class One obesity is usually BMI 30-35, Class Two is usually BMI 35-40, and Class Three is BMI over 40.

In this study, nearly half of Class One obese women needed a large cuff, and with Class Two and above, 100% needed a large cuff.  

My BMI is about 48 and has been for all four of my pregnancies, which occurred in the mid-90s through the mid 2000s.  Research on the importance of blood pressure cuff size in "obese" people had been around for years before that, yet getting the correct cuff size was a problem in three of my four pregnancies.

And I still hear stories about use of the wrong cuff size from other high-BMI women, inside and outside of pregnancy, even today.

In theory, care providers know about the importance of the correct cuff size, but in practice, many don't follow the guidelines, don't think cuff size really makes that much difference, don't really check what size cuff was used (even when encountering a high BP in a large person), and don't emphasize the importance of cuff size adequately to the nurses and techs who do the actual BP measurements most of the time.

Yes, BP taken at the wrist with a regular cuff can be done for a ballpark figure in high-BMI people, but is not accurate enough for decision-making purposes. It tends to overestimate blood pressure in many cases.


A large or thigh cuff  (depending on arm circumference) used on the arm is the only really accurate method of BP measurement in "obese" people.

You need accurate data on which to base care decisions. Ensuring the correct cuff size is a very simple but extremely important way that care providers can improve care for women of size.

Hypertens Pregnancy. 2011;30(4):396-400. Body Mass Index and Blood Pressure Measurement during Pregnancy. Hogan JL, et al.  PMID: 20726743

Objective. The accurate measurement of blood pressure requires the use of a large cuff in subjects with a high mid-arm circumference (MAC). This prospective study examined the need for a large cuff during pregnancy and its correlation with maternal obesity.

Methods. Maternal body mass index (BMI), fat mass, and MAC were measured.

Results. Of 179 women studied, 15.6% were obese. With a BMI of level 1 obesity, 44% needed a large cuff and with a BMI of level 2 obesity 100% needed a large cuff. 

Conclusion. All women booking for antenatal care should have their MAC measured to avoid the overdiagnosis of pregnancy hypertension.

PCOS: How Does PCOS Affect Women?

Poster by Amanda Kohn, www.implementingdesignism.org

We've just started a new series on Polycystic Ovarian Syndrome (PCOS) in honor of September, PCOS Awareness Month. 

In the first entry, we discussed its definition and symptoms, and why PCOS is somewhat controversial in fat-acceptance circles. 

In this post, we're going to describe how PCOS affects women, how if often develops and presents, and how it can affect women down the line as they age. 

In later posts, we will discuss testing and diagnostic issues, its effects on fertility, pregnancy and breastfeeding, and give more details on how it affects menopause and aging. 

Readers should know that we'll be doing this mostly from a size-acceptance point of view, rather than the usual "you have to diet" point of view present in most PCOS websites.  Weight loss will be discussed as only one possible treatment ─ with an honest look at the potential benefits and drawbacks of weight loss as treatment ─ but other alternatives will be emphasized.

What Does PCOS Look Like?

As one article puts it, "Polycystic ovarian syndrome is a clinically, histologically, and biochemically heterogeneous condition."  Translation: PCOS presents in each woman a little bit differently.

The Classic Presentation

The classic case is a woman who:

• is quite heavy
• has very irregular or totally absent periods
• has facial hair growth on her upper lip and/or chin (and often elsewhere)
• has dark patches of skin in various places on her body
• has skin issues, with cystic acne well into adulthood
• struggles with infertility issues
• has trouble getting or staying pregnant
• probably gained a lot of unexplained weight at some point
• has struggled with her weight ever since, often yo-yoing up and down chronically
• has slightly enlarged ovaries with many cysts on them
• has health issues such as glucose intolerance/diabetes, high cholesterol, and blood pressure concerns

Women like these are fairly easy to diagnose with PCOS because their symptoms are so clear.  The main markers looked for in PCOS (irregular periods, physical signs of too many androgens, and cystic ovaries) are obviously present. 

Sadly, however, even women with obvious cases of PCOS often go undiagnosed. It's very common for these women to see many doctors for their symptoms before someone realizes what is going on.  Too often, her weight is blamed as the source of her symptoms and all other possibilities are ignored.  Sometimes, the woman figures out her PCOS status on her own from the internet or a friend, and only then can she get the testing she needs.

Although Stein and Leventhal first "discovered" this condition in 1935, it has taken a long time for doctors to really take it seriously.  It is only in the last 10-20 years or so that awareness of it has really taken off.  Even so, many providers still just want to blame the woman for being fat and not look deeper for other possible mechanisms.  They view fatness as the cause, and refuse to believe fatness could merely be a symptom of a deeper problem instead.

Variations in Presentation

Of course, not every case of PCOS follows this classic profile.  If it's hard for women with very obvious symptoms of PCOS to get diagnosed, imagine how hard it is for someone whose case is more subtle!

For example, not all women with PCOS are fat. Some women with PCOS are average-sized ─ but still have very strong issues with insulin resistance and fertility (like actress Emma Thompson). It is unknown why some women with PCOS have weight issues and others do not. It's probably not due to differences in eating patterns but rather to some unknown metabolic difference.  Whatever the reason, it can be hard for the skinny woman with PCOS to get diagnosed.

But generally speaking, a lot of women with PCOS have very significant weight issues. The usual statistic quoted is that 50-60% of women with PCOS are "obese" ─ but because many doctors underdiagnose the condition in fat women, it's possible the percentage may actually be higher.

Hirsutism is extremely common in women with PCOS (some sites estimate it is present in 70-80%), but not every woman experiences it.  Some have only a little body hair and no facial hair, yet because doctors really look for facial hair as a sign of androgen excess, women without this classic sign are sometimes told they don't have PCOS, despite other pertinent symptoms.

Thinning scalp hair is much less common than hirsutism as a symptom, but is often overlooked as a potential sign of androgen excess.  And because many women find ways to cover this up or are too embarrassed to mention it to their doctors, it is underused as a symptom for diagnosis.

Fertility is another symptom that can vary.  Many women with PCOS have significant fertility issues, yet not all do. For some, it's closely tied to co-morbidities like hypothyroidism; if they treat that, fertility is less of an issue.  Sometimes, fertility for PCOS women is okay in younger years but declines over time, so some only develop infertility later on as the condition progresses.

Although some doctors consider fertility issues central to the diagnosis of PCOS, some women show clear skin and metabolic symptoms of PCOS yet never have problems conceiving or maintaining a pregnancy. Still, they may benefit greatly from treatment of the metabolic issues of PCOS, so many providers have begun to expand their definition of PCOS beyond  its past focus on infertility.

Clearly, the heterogeneous nature of PCOS means that there are many gray areas in diagnosis.

How Does PCOS Develop?

PCOS tends to run in families, and can come from either side of the family (mother or father). If lots of women in your family struggle with their weight, have irregular periods, diabetes, hypertension, and other common consequences of PCOS, the chances that you might have PCOS are higher.  Or if the males in your family have lots of premature balding and metabolic syndrome, this may also indicate a familial predisposition towards PCOS.  However, it takes a combination of genetic and environmental factors for PCOS to manifest itself, so not every family member is always affected.  Family history is a clue, not an automatic indication.

Often PCOS first presents a few years after periods begin (although some with very severe cases may show symptoms like acanthosis nigricans and significant fatness even well before puberty). Typically, menstruation begins normally, but within a few years, periods begin to skip here and there. Eventually, menstrual issues worsen; some develop long cycles (more than 35 days), some develop erratic cycles, some skip whole sets of periods, while the most severe cases stop cycling completely.

At some point most women with PCOS develop secondary skin-related symptoms like hirsutism, thinning hair, or significant acne (especially boil-like sebaceous cysts under the skin).  These can be quite distressing socially, so this is often when these women begin to seek medical answers, often without success.

It's not unusual for many woman with PCOS to experience a significant, unexplainable weight gain ─ with no change in habits ─ in her late teens or twenties (and sometimes later too); this is often despite similar caloric intakes as women without PCOS.  As one website notes:

Approximately 60% of women with PCOS have weight management issues which can lead to obesity with only normal caloric intake. Energy in the form of glucose (food) is stored right away as fat, instead of being made available for other functions within the body. This can lead to chronic fatigue and undernourishment, despite the fact that there is adequate food intake and even an appearance of overnourishment. 

Those with the most severe cases of PCOS may become supersized because of a vicious cycle of insulin resistance and yo-yo dieting. High levels of insulin in the blood lead to weight gain, so women diet to lose weight, only to regain to an even higher weight as the body's metabolism reasserts itself. Concurrent hypothyroidism can greatly exacerbate this gain. Some women develop eating disorders (compulsive overeating or binge eating disorder) as a result of years of dieting, and many experience very strong carb cravings due to hyperinsulinemia. Thus it can be difficult to untie the influence of insulin issues, yo-yo dieting, eating issues, and disease co-morbidities on weight, but there is often a synergistic effect of all of them together.

In some women, PCOS symptoms accelerate and worsen with time. Those with the most severe cases usually have great difficulty conceiving, often develop diabetes and/or high blood pressure in their twenties or thirties, struggle with sleep apnea and other complications, and become "super obese" at some point from a combination of factors. Co-morbidities like sleep apnea are common, and as a result, many get so desperate they resort to bariatric surgery to try and mitigate their symptoms, regain some mobility, or have a chance at pregnancy.

In other women, the symptoms stay relatively mild throughout their life or progress much more slowly. Often, normal blood sugar and blood pressure are maintained for years, and the only signs of metabolic derangement are subtle differences in labs; a tendency towards weight gain, reactive hypoglycemia and/or gestational diabetes; and skin symptoms (like sebaceous cysts, acne, or thinning hair).  However, the symptoms often worsen significantly around or just after menopause, and many are diagnosed with issues like hypertension or diabetes at this time. 

A lot depends on the woman's pancreatic beta-cell function. If the pancreas is capable of producing enough insulin to compensate for the insulin resistance in the body, blood sugar remains in the normal range. In those whose beta cell function is compromised, the body is not able to produce enough insulin to overcome the insulin resistance and diabetes develops early.

Some women think that as long as their blood sugar and blood pressure is fine and they don't want children, PCOS is not a big worry.  However, just because blood sugar is normal doesn't mean the body is okay; it still has to deal with the side effects of too much insulin and too many androgens in the body.  And over the years, this can take a toll, even on those with milder cases.

How Does PCOS Affect Long-Term Health?

As women with PCOS age, the metabolic consequences of years of hyperinsulinemia and excess androgens begin to accrue.

Although you might expect that PCOS symptoms would disappear after the ovaries shut down at menopause, many find that some symptoms actually worsen after menopause instead.

Hirsutism on the face may get even worse, and the hair may thin even more than before. Acne doesn't go away, and problems like sleep apnea may worsen.

Chronic overproduction of insulin also tends to lead to hypertension over time, and it exhausts the pancreas. Therefore even those who had relatively good pancreatic beta cell function and normal blood sugar and blood pressure for years tend to develop diabetes and hypertension as they age.

This means that PCOS has life-long health implications.  The tendency towards blood sugar, insulin resistance, blood pressure issues and perhaps an increased rate of clotting means that vascular disease often develops.  Many women with PCOS develop heart disease, and may also have a tendency towards stroke.

High levels of androgens may also be connected to the development of non-alcoholic fatty liver disease (NAFLD).  One study found more than three times the risk for NAFLD in women with PCOS, even after controlling for BMI and other factors. Higher androgen levels are thought to be the culprit but this still remains speculative.

Cancer is another potential risk.  If the woman does not cycle regularly, the uterine lining can build up and endometrial hyperplasia (overgrowth) can develop.  Unchecked, this can lead to a higher chance of endometrial cancer.  PCOS is clearly associated with a higher risk for endometrial cancer.

Is PCOS connected to the development of other cancers?  Some research ties PCOS to a higher rate of ovarian cancer, but research on this is contradictory and unclear. In addition, insulin resistance and hyperinsulinemia may be tied to a stronger risk for colo-rectal cancer. Many researchers speculate that the relatively high rate of unopposed estrogen in PCOS may increase the risk for postmenopausal breast cancer too, although nothing has really been proven at this point.

The connection between PCOS and these different cancers is still being untangled and answers are far from definitive, but clearly there is an increased risk for endometrial cancer at the very least.

Psychological Effects of PCOS

Psychologically, PCOS is a brutal condition.

In its most severe form, a woman is stripped of nearly everything that society sees as womanly, a "theft of womanhood," as some sources call it. She probably is very fat, balding, has a mustache or other facial hair, has acne and body tags, doesn't cycle regularly, and has difficulty having children.  She is seen as sexually unattractive, epitomizes the image of the "ugly" woman in our society, and is the object of many jokes and much derision in the media.  Is it any wonder some women find this condition incredibly demoralizing?

Adding into this is the lack of understanding around PCOS as a condition.  Even when you have an official diagnosis, some friends and family consider it a dubious finding.  In their view, you're just looking for an excuse for being fat, crying about how your "bad metabolism" causes your obesity, instead of taking responsibility for your supposedly poor eating. They roll their eyes or accuse you of closet binge-eating instead.

Doctors often don't believe you if you tell them you eat normally either, thinking you must be in denial about your eating, or that you are too uneducated about "proper" nutrition to really understand how to eat healthy.  Furthermore, the shopping cart and food intake of a woman with PCOS are under continuous scrutiny and criticism, adding constant stress to daily life.  The "obese" woman with PCOS always feels on the defensive about her food or exercise habits.

This disbelief about their experiences and the burden of constant surveillance often takes a considerable toll on PCOS women's self-esteem. And for those who truly do struggle with eating disorders after years of dieting, the shame around dealing with that on top of PCOS can be overwhelming.

Some resources list depression and/or anxiety as one of the possible side-effects of PCOS.  It's not clear whether the tendency towards this has a physiological basis, is merely a by-product of mistreatment by society, or is a combination of both. Since many women with PCOS tend to have borderline hypothyroidism (and depression can be a symptom of hypothyroidism), there may be a good argument for a physiological basis.  On the other hand, the harassment that women with PCOS receive in society could cause anyone to feel anxious or depressed. Or there may be a synergistic effect between the two.

Either way, there is no doubt that it is very difficult to be a woman with PCOS in our society. Yet the situation is not without hope.  Many women with PCOS are able to develop a sense of peace with their body, an inner strength to help overcome the biases superimposed by society.  Women with PCOS can be strong and assertive and body-positive; it isn't easy with negative messages all around, but it is possible..

Conclusions

Clearly, PCOS is a difficult condition that deserves to be taken more seriously. 

Knowledge about PCOS is evolving, but not all care providers are familiar with this condition. Some don't believe it really exists, some believe it's far more about being fat than about metabolic abnormalities, some apply too-stringent diagnostic criteria, while others diagnose it without ruling out other possibilities first. Therefore it can be very difficult to get an accurate diagnosis.

Unfortunately, there's no one "official" test you can take that will tell you that you do or don't have PCOS. Often diagnosis is less than clear-cut because of co-morbidities and the variability of symptoms.

So even if you've been told that you don't have PCOS, you might simply be at a less severe level on the PCOS spectrum ─ not severe enough for diagnosis, but not clearly "normal" either. Or you might have a phenotype that your doctor did not recognize.  Or you might have something that looks like PCOS but is actually caused by another condition.  Or you might not have PCOS at all.

Sometimes the answers are elusive and what you are told will vary from provider to provider.  This is why it's important to keep asking questions, keep searching for a really good provider, always get copies of your labs and tests, and keep a file of them over the years.  It's not uncommon for it to take multiple visits for this condition to get recognized, for testing to be done (or interpreted) incorrectly, or for an optimal treatment plan to be developed.  Persistence and good record-keeping is very important.

In the past, some doctors viewed PCOS as a concern only if you wanted to get pregnant, but research indicates it has significant life-long health implications, including higher rates of diabetes, hypertension, heart disease, and some types of cancer later in life. 

Because of its implications for long-term health, PCOS deserves to be taken seriously, regardless of the patient's age or whether or not they want children. It needs to be seen as a life-long condition, not just a concern tied to pregnancy.

In the next entry in this series on PCOS, we will talk more about the testing and diagnosis of PCOS. Stay tuned for further entries about PCOS in the future as well.


References

*Trigger Warning: Not all resources/studies listed here are size-friendly but are listed because they may have some other valuable information or resources.  Approach with caution.

General Information and Support for Women with PCOS

www.pcosupport.org
www.soulcysters.com

Genetics and PCOS

• http://www.ncbi.nlm.nih.gov/pubmed/16728382 - interaction of genetics and environmental factors in PCOS
• http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1820621/?tool=pmcentrez - familial clustering in PCOS

PCOS and Dietary Intake

Int J Obes Relat Metab Disord. 2004 Aug;28(8):1026-32. Dietary intake, physical activity, and obesity in women with polycystic ovary syndrome. Wright CE, Zborowski JV, Talbott EO, McHugh-Pemu K, Youk A.  PMID: 15159768

"Although women with PCOS had a higher BMI than control women, an overall comparison of women with and without PCOS showed no significant difference in dietary intake. However, stratification by BMI revealed that lean women with PCOS reported significantly lower energy intake than lean women without PCOS.  CONCLUSION: Differences in dietary intake and physical activity alone are not sufficient to explain differences in weight between women with and without PCOS."

Gynecol Endocrinol. 2011 May 24. Diet composition and physical activity in overweight and obese premenopausal women with or without polycystic ovary syndrome. Alvarez-Blasco F, et al.  PMID: 21609197

"We aimed to find differences in diet and life-style that might contribute to the development of PCOS among overweight or obese premenopausal women. We compared diet composition and self-reported physical activity among 22 patients with PCOS and 59 women without androgen excess recruited from a total of 113 consecutive premenopausal women reporting for management of weight excess. After correcting for a difference in age between women with PCOS and controls, there were no overall statistical significant differences between them in the total caloric intake, in the intake of macro- and micro-nutrients, caffeine, fiber and alcohol, in the proportion of women exercising regularly, or in the number of hours of exercise per week. The proportion of fat in the diets of the overweight and obese women irrespective of PCOS was well-above current recommendations, yet this excessive fat intake occurred at the expense of monounsaturated fatty acids mostly. In conclusion, diet composition and physical activity were apparently not decisive for the development of PCOS among overweight and obese premenopausal women."

PCOS and Psychological Effects

• http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3108690/?tool=pubmed - Psychological effects of PCOS, as well as possible long-term health risks
• http://www.ncbi.nlm.nih.gov/pubmed/18672334 - Depression, anxiety, and suicide attempts among women with PCOS
• http://www.ncbi.nlm.nih.gov/pubmed/19454378 - Depression and affective disorders in PCOS
• http://www.ncbi.nlm.nih.gov/pubmed/18249398 - Depression, mood disorders, and binge eating disorder in women with PCOS over time

PCOS and Long-Term Health Risks

• http://pcos.about.com/od/relatedconditions/a/endocancer.htm - PCOS and risk of endometrial cancer
• http://humupd.oxfordjournals.org/content/7/6/522.full.pdf - PCOS and cancer risks
• http://www.ncbi.nlm.nih.gov/pubmed/20111659 - PCOS and cardiovascular risks
• http://www.ncbi.nlm.nih.gov/pubmed/21335359 - PCOS, heart disease, and strokes
• http://www.ncbi.nlm.nih.gov/pubmed/21251033 - PCOS and non-alcoholic fatty liver disease

Breastfeeding Lowers the Risk for Diabetes And Other Maternal Disease Later In Life

There's an interesting new study out on breastfeeding and later diabetes in the mother. 
It found that breastfeeding for at least one month lowered the mother's risk for developing diabetes later in life, even after controlling for many confounding factors such as physical activity status, BMI, etc. 

Interestingly, women who had given birth but not breastfed for at least a month were at greater risk for diabetes later on than women who had never given birth at all.  That was a surprising finding.

According to a discussion of the study at the Breastfeeding Medicine blog:

The study included 2,233 women between the ages of 40 and 78 who were members of a large integrated health care delivery organization in California. Strikingly, one of every four mothers who had never breastfed had developed type 2 diabetes.

Mothers who had not breastfed were almost twice as likely to develop diabetes as women who had breastfed or women who had never given birth. These long-term differences were notable even after considering age, race, physical activity and other factors which affect risk of diabetes such as alcohol and tobacco use...

In other words, breastfeeding is part of the way mothers’ bodies recover from pregnancy. When this process is interupted, and an infant is fed something other than...mother’s milk, a mother’s body suffers.

The authors did control for BMI and physical activity in the analysis, among other things. According to the study's abstract:

Multivariable logistic regression was used to control for age, parity, race, education, hysterectomy, physical activity, tobacco and alcohol use, family history of diabetes, and body mass index while examining the impact of duration, exclusivity, and consistency of lactation on risk of having developed type 2 diabetes.

A couple of limitations of the study are its fairly small size --- 2233 women total, only 1828 of whom were mothers --- and its low threshold for length of breastfeeding (greater than or equal to 1 month of breastfeeding). 

That means the study had only 1024 women who breastfed 1 month or longer, and while that's nothing to sneeze at, you really need a bigger data set, looking at a longer duration of breastfeeding, to prove population-wide effects most clearly. 

Sadly, only 56% of the women in the study had breastfed their children for more than one month, another limitation of the study.  This very low rate almost certainly reflects the age of the women in the study (40-78) and the active discouragement of breastfeeding many of the older women encountered.

Still, the study reports a striking finding and yet another reason to pursue breastfeeding. 

It also points out what a disservice doctors did to women years ago when they actively discouraged breastfeeding, and the dangers of sweeping health policies that interfere with the way our bodies were designed to undergo pregnancy, birth, and postpartum.

Previous research on Breastfeeding and Later Diabetes

Some previous research has also tied length of breastfeeding to a lower risk for later diabetes in mothers. 

A Chinese study (Villegas 2008) found that breastfeeding modestly lowered the risk for later diabetes in women followed for just under 5 years.  They reported:

Women who had breastfed their children tended to have a lower risk of diabetes mellitus than those who had never breastfed [relative risk (RR)=0.88; 95% CI, 0.76-1.02; p=0.08]. Increasing duration of breast-feeding was associated with a reduced risk of type 2 diabetes mellitus. The fully adjusted RRs for lifetime breast-feeding duration were 1.00, 0.88, 0.89, 0.88, 0.75 and 0.68 (p trend=0.01) for 0, 0 to 0.99, 0.99 to 1.99, 1.99 to 2.99, 2.99 to 3.99, and greater than or = 4 years.

One of the largest studies on breastfeeding and maternal diabetes was published in The Journal of the American Medical Assocation (Steube 2005).  It used large datasets from the Nurses Health Study (121,700 women from 11 states) and the Nurses II Health Study (116,671 women from 14 states) to study the effect of lifetime duration of breastfeeding on later risk for diabetes. They found:

Among parous women, increasing duration of lactation was associated with a reduced risk of type 2 diabetes. For each additional year of lactation, women with a birth in the prior 15 years had a decrease in the risk of diabetes of 15% (95% confidence interval, 1%-27%) among NHS participants and of 14% (95% confidence interval, 7%-21%) among NHS II participants, controlling for current body mass index and other relevant risk factors for type 2 diabetes...

Longer duration of breastfeeding was associated with reduced incidence of type 2 diabetes in 2 large US cohorts of women. Lactation may reduce risk of type 2 diabetes in young and middle-aged women by improving glucose homeostasis.

So there's a study with a very large dataset that found that breastfeeding -- the longer the better -- lowered the risk of mothers developing type 2 diabetes later on.

Keep in mind that this study also reflected our society's tendency towards short breastfeeding periods.  They traced a woman's lifetime exposure to lactation (how long she breastfed all her children cumulatively), and their highest category was "greater than 23 months." 

Greater than 23 months over your lifetime?  Heck, I breastfed every single one of my kids at least that much each time, so how does that affect my risk for type 2 diabetes?  My total lifetime exposure to lactation is right around 10 years.  Does each additional cumulative year above 23 months help lower my risk that much more?  The Chinese study cited above seems to suggest so, but its maximum lifetime exposure category was greater than or equal to 4 years.

I would love to seen the JAMA researchers collect information about a far greater lenth of total lactation in U.S. women than 23 months, but the fact is that our long-term breastfeeding rates in this country are so poor that they probably would  have had trouble finding enough women to make such a sub-analysis statistically meaningful. How sad is that?

The study did have a small subanalysis on how lactation affected risk for diabetes in women with significant risk factors, like women with high BMIs, women who had gestational diabetes during pregnancy, etc. They found:

In the NHS II cohort, higher BMI at age 18 years was associated with shorter duration of breastfeeding, and in both cohorts, duration of lactation was inversely associated with family history of diabetes. Gestational diabetes was not associated with duration of lactation. Nevertheless, adjustment for family history and BMI at age 18 years did not substantially diminish the inverse association between lactation and risk of type 2 diabetes, suggesting that the association we observed was not an artifact of pregravid or pregnancy obesity and its associated insulin resistance. However, stratification by history of gestational diabetes revealed that in this high-risk group of women, lactation did not affect risk of subsequent type 2 diabetes.

While it was encouraging that the protective effect of breastfeeding was present for women of size too, it was certainly discouraging that the protective effect did not seem present in women with gestational diabetes.  However, a recent smaller tudy (Gunderson 2010) found a lower rate of metabolic syndrome in women with GD who breastfed longer, so further study seems to be indicated.

Regardless, breastfeeding is always worthwhile because of the tremendous immunological benefits and superior nutrition that breastmilk provides to the baby.  Furthermore, there is research that suggests that breastfeeding is protective against the baby developing diabetes later in life.  For example, Pettitt 1997 found that breastfed infants of Pima Indians (a group at very high risk of diabetes) had less than half the risk for diabetes later in life compared to those who had been bottlefed:

The odds ratio for NIDDM in exclusively breastfed people, compared with those exclusively bottlefed, was 0.41 (95% CI 0.18-0.93) adjusted for age, sex, birthdate, parental diabetes, and birthweight.

One important question is how long the maternal benefits of breastfeeding last. The JAMA study did find that as time went on, the protective effects of breastfeeding against maternal diabetes began to fade. They noted:

In these analyses of 2 large prospective cohorts, we found that duration of lactation was inversely associated with risk of type 2 diabetes in young and middle-aged women, independent of other diabetes risk factors, including body mass index, diet, exercise, and smoking status. This association appeared to wane with time since last birth.

Perhaps long-term breastfeeding has more of a delaying effect than a prevention effect on diabetes, especially in women with very strong risk factors for the disease. 

Another interesting finding was that the longer the period of exclusive breastfeeding, the greater the effect against diabetes.  As the authors noted in their discussion:

Our data on exclusive breastfeeding and duration stratified by parity suggest that the length and intensity of breastfeeding with each pregnancy affect the association with diabetes risk. We found that each year of exclusive breastfeeding was associated with a greater risk reduction than total breastfeeding. This may reflect the greater metabolic burden imposed by exclusive breastfeeding.

We also found that longer durations of breastfeeding per pregnancy were associated with a greater benefit, with 1 year’s lactation for 1 child resulting in a 44% reduction in age-adjusted risk, compared with 1 year’s lactation between 2 children resulting in a 24% reduction in risk.

It appears from our analysis of primiparous women that the beneficial association begins to accrue after 6 months of lactation. These data suggest that sustained lactation-associated metabolic changes have more profound effects on diabetes risk.

This was an encouraging study because it shows in yet another way just how important breastfeeding is --- not just for the baby, but also for the mother. 

However, on a personal note, despite research showing that long-term breastfeeding decreases the risk for type 2 diabetes, I still think there's a very strong possibility that I will get it at some point, despite my 10 years of breastfeeding exposure.  PCOS reflects an underlying metabolic abnormality that no one knows how to "fix" at this point, and breastfeeding's improvements in insulin sensitivity and glucose tolerance probably only end up delaying the progression of that metabolic abnormality, not fixing it permanently.

Still, the less time you have diabetes, the less cumulative damage there is from it to your body, so even a delaying effect could have considerable impact on your long-term health.  I hold that thought close. And of course I do what I can to lower my risk in other ways.

What About Other Maternal Diseases?

Findings from other studies show that longer breastfeeding duration is not only protective against diabetes, but also against hypertension, high cholesterol, and heart disease.  In Schwarz 2009, for example, data from the large Women's Health Initiative study found that longer breastfeeding was associated with lower risk factors and less cardiovascular disease:

Dose-response relationships were seen; in fully adjusted models, women who reported a lifetime history of more than 12 months of lactation were less likely to have hypertension (odds ratio [OR] 0.88, P less than .001), diabetes (OR 0.80, P less than .001), hyperlipidemia (OR 0.81, P less than .001), or cardiovascular disease (OR 0.91, P=.008) than women who never breast-fed, but they were not less likely to be obese. In models adjusted for all above variables and BMI, similar relationships were seen...

Over an average of 7.9 years of postmenopausal participation in the Women's Health Initiative, women with a single live birth who breast-fed for 7-12 months were significantly less likely to develop cardiovascular disease (hazard ratio 0.72, 95% confidence interval 0.53-0.97) than women who never breast-fed...

Among postmenopausal women, increased duration of lactation was associated with a lower prevalence of hypertension, diabetes, hyperlipidemia, and cardiovascular disease.

These findings were echoed in another large study (Steube 2009) that found that women who had a lifetime breastfeeding exposure of at least 2 years had lower risk for heart attacks/cardiovascular disease than parous women who had never breastfed. 

Compared with parous women who had never breastfed, women who had breastfed for a lifetime total of 2 years or longer had 37% lower risk of coronary heart disease (95% confidence interval, 23-49%; P for trend less than .001), adjusting for age, parity, and stillbirth history. With additional adjustment for early-adult adiposity, parental history, and lifestyle factors, women who had breastfed for a lifetime total of 2 years or longer had a 23% lower risk of coronary heart disease (95% confidence interval, 6-38%; P for trend = .02) than women who had never breastfed.

These findings mean that there's a lot of potential room for prevention (or or at least delaying) of diabetes, heart attacks, and other health issues, just by promoting higher rates of breastfeeding....and in particular, promoting breastfeeding for longer durations.

Dealing With Blood Pressure Miscuffing Proactively

We've been doing a series about the importance of the correct-sized blood pressure cuff, especially for people of size. "Obese" people are often miscuffed, leading to overestimation and overtreatment of their blood pressure at times.

We've discussed measuring your own arm and using that measurement to know which cuff size you should use, and how to buy your own cuff if needed. We've shared some of our own miscuffing stories, and discussed how miscuffing seems to be particularly common in pregnancy and can lead to many unnecessary interventions if not caught.

Today, in the last of the series, we're going to talk about overcoming resistance from healthcare workers about miscuffing, and being proactive healthcare consumers if miscuffing occurs.

Miscuffing General Guidelines

Using the wrong blood pressure cuff size is actually pretty common. That's why it's so important to measure your arm size and know which cuff you should use. Basically, the guidelines are:

• if your arm is over about 13.4 inches (34 cm), you should be using a "large" adult cuff


• if your arm is over about 17.7 inches (45 cm) or so, you should be using a "thigh" cuff (although the cuff range in this size is less standardized and you should read the range on the side of the cuff each time)


• if your arm is over about 20.5 inches (52 cm), you need a special-order cuff size, which you can get from http://www.amplestuff.com/.

Remember, it's NOT about whether the cuff can fit around your arm; the issue is actually whether the bladder size inside the cuff is the appropriate length and width for your arm size. A cuff can go around your arm just fine and still have the wrong-sized "bladder" inside the cuff and cause inaccurate measurements.

Research is VERY clear that fit is NOT the critical issue; length and width of bladder is.

Chances are that if you are significantly "overweight" or "obese" or if your arms tend to be larger/heavy, you probably need the large cuff. Supersized people often need the thigh cuff. So generally speaking, you can probably guess at your cuff size. But really, it's best to know your own arm size (in centimeters!) so you can be sure which cuff size you need.

Resistance from Healthcare Workers

Research from the latest NHANES survey of the American population showed that 42% of all men and 26% of all women aged 40-59 years (which is when hypertension often starts to show up) required large BP cuffs.

You would think that this would mean that doctor's offices and hospitals would routinely carry large cuffs and that healthcare workers would automatically get the larger cuff when needed, wouldn't you?

But no, miscuffing seems to be a pretty common experience among people of size. Anecdotally, many have more than one miscuffing story to share. It is probably more common than most medical authorities realize.

Unfortunately, it can be difficult to convince some healthcare workers to use the appropriate cuff, despite years of research on the topic. Sometimes this is just simple ignorance or improper training about the difference cuff size can make. Sometimes, though, the resistance goes deeper than mere misinformation or ignorance.

Some doctor practices don't own a large cuff in order to save money or because they haven't really thought the matter through. It's not that they are trying to discriminate; it's more a matter of cutting corners on a tight budget or simply not even thinking about cuff sizes.

[But frankly, if this is true of your doctor's practice, you should be questioning whether you should even be going there. A large cuff (and a thigh cuff!) should be standard equipment for every practice; if it's not, it shows the practice is not very aware of important issues for people of size. If you have a choice, find another, more size-friendly practice.]

Some healthcare workers will tell you that the large cuff is "broken" or "out for repair" or "can't be found." Sometimes this might even be true.....but often, it's an evasion to hide the fact that the practice hasn't bothered to buy a larger cuff, or to hide the fact that they are too lazy/busy to go find the larger cuff.

Mind, staff members are often overworked and very busy; hospitals in particular tend to understaff their wards these days. You can understand why an overworked nurse or medtech might not want to take the time to go find the large cuff or the thigh cuff hidden in some obscure cupboard somewhere.

But it doesn't matter. That's their job. They NEED to get the most accurate measurements possible because all your treatment decisions will be based on these numbers. Even if it is inconvenient, it is critical that they use the correct equipment for the job.

Sometimes medical workers will say things like, "cuff size doesn't make that much difference at your size," or "as long as the cuff goes around your arm it'll be fine," or "a forearm reading is just as good"----but none of these stand up under closer investigation.

Cuff size really does matter and often makes quite a bit more than a "couple of points" of difference.....sometimes it can make 50 points or more difference. And it's not whether the cuff goes around your arm, it's whether the bladder inside the cuff is the right proportion to your arm. Furthermore, while a forearm reading can do in a pinch, it tends to overestimate blood pressure and should not be relied on unless there truly is no other choice (and then only on an occasional basis).

All of these are merely excuses.....unacceptable excuses.....for trying to get away with using the wrong equipment. Don't let them con you into acquiescing; insist on the correct equipment for the job every time.

What If Miscuffing Happens To You?

If the wrong blood pressure cuff is brought out for you, the best thing to do is to politely refuse to have your blood pressure measured at all. You don't need to be confrontational about it since it's helpful to maintain a good relationship with the staff, but you do need to be politely firm about it.

Remember, invalid data on your permanent record is worse than no data at all. Insurance workers may determine your eligibility for life insurance or health insurance or other programs based on reviews of your medical files; a spuriously high reading may impact your ability to get insurance (or cause you to have to pay more). Better not to have a reading on there at all than to have a spuriously high one.

Taking a blood pressure is a medical test like any other, and you ALWAYS have the right to refuse a test. You don't give up your rights when you walk through that clinic door; you always have the option to decline testing.

Of course, no one is advocating that you avoid blood pressure readings, just that you make sure that the data is accurate.

If they do not have the equipment needed, you are completely within your rights to refuse such a test. Just tell them politely but firmly that you would be happy to have your BP taken....once the correct-sized cuff is located. Until the correct cuff is available, tell them you choose to exercise your right of informed refusal.

Documenting and Protesting Miscuffing Issues

What if a healthcare worker refuses to let the issue go? What do you do?

First of all, try to educate them. Most healthcare personnel are genuinely in the profession to help people and are open to learning how to better serve special populations. Educate them about the need for the proper-sized cuff and how much miscuffing can affect BP readings. It may simply be a matter of not realizing how much difference cuff size can make.

Most of the time, a little polite education and persistence will be enough to eventually bring about the right cuff for the job. However, sadly, occasionally personnel refuse to listen or even indulge in bullying or manipulative tactics.

Medical bullying is real, and occasionally healthcare personnel can get very unpleasant. Just remember that you cannot be compelled to take a medical test against your will. Keep telling them calmly but firmly that use of an incorrectly-sized cuff gives invalid data and you will be happy to have your blood pressure taken when they use the correct cuff.

Use the phrase, "I do not consent," because this phrase has a stronger impact with medical personnel. Also remind workers that patients always have the right to informed refusal of any medical procedure or test. Make it clear that you do not object to taking the blood pressure itself, but that you refuse to have it taken with incorrect equipment because it will result in invalid data. Offer to sign an "informed refusal" form if needed.

If this is not enough, you can ask to see the healthcare worker's supervisor and share your concern. Request that another worker be assigned to you; this kind of request is actually not that unusual and supervisors are often able to accommodate such a request.

Ask a friend or a loved one to act as spokesperson for you if you are feeling poorly or find it difficult to communicate effectively or assertively. Having another voice there can make all the difference in the world when you are ill or find it difficult to speak up for whatever reason.

If you still find that medical personnel are unresponsive, ask to see a Patient Advocate. Most hospitals have one. Tell them that you have concerns about your needs being met as a person of size. Share with them the importance of using a large blood pressure cuff, and about resistance you have met.

The job of the Patient Advocate is to help represent your needs and to advocate for them. Because they have a recognized voice and role within the institution, they often have a great deal of influence and may be able to get needs met that might otherwise get ignored.

Registering a Patient Complaint

Being firm and assertive sounds all well and good in principle, but realistically, it's not always easy to be assertive in these situations, especially when you are feeling sick and vulnerable. Many people (including me) have been bullied into taking the BP with the wrong cuff, despite our protests. What then?

Don't be a silent victim. Even if you have been "convinced," manipulated, or downright bullied into taking a BP with the wrong cuff, it's not too late to try and change that behavior for yourself and for others in the future.

Document the experience and write a letter of complaint to the healthcare worker's supervisor. Be polite, no matter how upset you are; calmly recount what happened and cite research that shows how undercuffing can inflate blood pressure. Close by giving them a clear way to meet your concern; ask them to make sure a large cuff and thigh cuff are available at all times, ask them to re-train their workers on the importance of correct cuff size, etc.

Often, medical supervisors will be very responsive to this type of letter. The trick is to be polite, document your concerns with corroborating research, and to give them a concrete course of action to remedy the problem. You can also encourage responsiveness by forwarding a copy of the complaint to insurance or supervisors further up the management chain of command.

I wrote a letter of complaint like this several years ago after the urgent-care experience I wrote about previously, where the nurse conned me into a "science experiment" to see "if the large cuff really made any difference or not" (it did; 50 points of difference, but the erroneously high reading was still recorded in my chart).

I wrote a letter documenting the experience and sent it to the supervisors of the facility and my insurance. The supervisors immediately apologized to me, promised that a large cuff would be purchased for the facility, and promised that the staff trained on the importance of its use. I've been back to that facility since then, and they indeed did have the correct cuff (and used it).

Because of that experience, I developed a handout that can be sent along with a letter of complaint, documenting blood pressure cuff size guidelines and citing research on obesity and cuff size. It is available on my website, here, and I have given permission for it to be used for this purpose. Feel free to make use of it if you need it.

Some fat people (especially women) may feel guilty about being assertive like this. After all, women are often raised with the idea that "good girls" are always polite, always please others, and never complain. Also, as fat people, we are often taught that we don't deserve good treatment, that our needs and desires don't matter, and that it's not our place to question medical authorities. Some have been taught to be too embarrassed by the size of their arms to draw attention to them by demanding the right cuff.

But think about it. They are asking you to take a test with improper equipment, the inaccurate results of which could ultimately result in harm to you. You are completely within your rights to refuse testing under these circumstances, to advocate for the proper equipment, and to complain if medical personnel are not responsive to your concerns.

Don't feel that improper blood pressure technique is too trivial to complain about; if personnel are using incorrect technique or equipment to take blood pressure, sooner or later someone is going to be harmed by that. The mistake needs to be pointed out and corrected.

You are doing yourself a favor by insisting on correct equipment, but not only that, you are doing a favor for every fat person who comes after you.

Step up to the plate and be ready to advocate if needed.