Common Sense Prenatal Weight Gain Recommendations for "Obese" Women

The 2009 IOM Guidelines for Prenatal Weight Gain

Coming up with official prenatal weight gain guidelines is difficult. There's always a trade-off involved ─ too much weight gain increases the risk for large babies, but too little increases the risk for small babies.

(The effects of weight gain on cesarean rates and pre-eclampsia are harder to figure out because of multiple variables that influence outcomes, so we will limit our discussion for a moment to the influence of weight gain on fetal outcomes.)

This weight gain trade-off has been particularly difficult to figure out in women of size. We tend to have larger babies on average and a very big weight gain seems to increase fetal size particularly strongly in high-BMI women. Nor do we need to gain extra fat reserves for pregnancy and breastfeeding. As a result, the Institute of Medicine (IOM) recommends less weight gain on average for "obese" women (see chart above).

While I don't hate these recommendations, I do have some concerns with them, particularly for women in the borderline categories (see discussion below). Women in these categories may be particularly at risk for poor outcomes, yet they are given the same stringent guidelines (and are often told to gain even less than the guidelines).

I also question how much control women really have over gestational weight gains. Sure, we have control over how much we eat and exercise, but that impact on gain is fairly minimal. There have been many trials of interventions to help obese women keep their weight gains lower; some have had minimal success (about 5 lbs. difference), but many have made little difference in weight gain and do little to improve other outcomes. Even with the best support, many women of size gain above the guidelines ─ not because they are lazy or out of control, but because the guidelines aren't particularly realistic for them.

I am also concerned about harassment and over-intervention in the pregnancies of women who gain above these recommended ranges. I have heard many stories of women of size who are harassed or even punished with early inductions or planned cesareans because they "gained too much."

So while I agree in general with the IOM that obese women don't need to gain as much weight in pregnancy as other women, I do have some reservations about the IOM guidelines and in particular about how they are implemented. But sadly, even these guidelines are not stringent enough for some providers.

Taking The 2009 Guidelines Even Further

Some caregivers believe the 2009 IOM weight gain goals didn't go far enough for obese women. In recent years, unofficial prenatal weight gain advice has gotten progressively more extreme. I call this the "anorexation" of pregnancy weight gain guidelines.

The following are real-life headlines from media articles over the years. Notice how the headlines have changed. They have gone from "obese women should gain LESS weight".....

...to "obese women should gain NO weight"

....to "obese women should LOSE weight" during pregnancy.

Disturbingly, many experts have taken an extremist tone in the media and sold these draconian measures as a public health imperative, which alarms me greatly. Many news articles have pushed this weight restriction agenda, assuring us that very little gain was perfectly safe and even healthier for the plus-sized mother and her baby. Here are just a couple of examples.

One article about the IOM recommendations prominently featured the following quotes promoting even lower gains in high-BMI women:

"I think 11 to 20 pounds is way too much for an obese woman," said Dr. Thomas Myles, a professor of obstetrics and gynecology at Saint Louis University School of Medicine who was not involved in the current recommendations. "I usually tell my [obese] patients that gaining less than 10 pounds and even losing up to 10 pounds is appropriate, whereas for overweight women, gaining 10 to 15 and even up to 20 pounds is appropriate," Myles said. 

Gaining a little less weight than the recommended amount, especially for overweight and obese women, might be better, [Associate Professor, Dr. Emily] Oken [of Harvard University] said.

Another article promoting zero weight gain in obese women featured the following quote from one of its leading investigators in its study's press release (my emphasis):

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

Another recent article quoted Dr. Sigal Klipstein, Chair of the American College of Obstetricians and Gynecologists committee on Medical ethics. Even as she discussed the importance of treating obese women humanely during pregnancy, Dr. Klipstein stated:

Although women should not to try to lose weight during pregnancy, “a woman who weighs 300 pounds shouldn’t gain at all,” Klipstein said. “This is not harmful to the fetus.”

But is it really true that very small or non-existent gains are not harmful?

Risks of Too-Small Gains

Those who suggest that gaining little or no weight is optimal for women of size are ignoring all the contrary research.

A significant amount of research has shown that very low weight gains and/or weight loss during pregnancy in women of size carries real risks, including

• prematurity (Dietz 2006, Potti 2010, Hasegawa 2012)
• too-small babies (Vesco 2011, Catalano 2014)
• more need for intensive care in the NICU (Potti 2010)

Tellingly, virtually NO media articles acknowledge that low weight gains have risks or cite the research that shows this. That there are so many articles promoting restricted gain in obese women while completely ignoring the potential harms of such a policy suggests a health agenda that places ideology over evidence.

And now there is even more research suggesting that very low gains may be risky.

A very recent study (Durst 2016) showed that weight gains below the IOM recommendations in obese women led to increased rates of  small-for-gestational-age ("SGA") babies and pre-term births. Another recent study (Cox Bauer 2016) found that gestational weight loss (GWL) was associated with low-birth weight babies. These are a concern because too-small babies are more at risk for future health problems like metabolic syndrome and insulin resistance.

Still another recent study (Hannaford 2016) shows that too-low weight gains, even in obese women, more than doubled the risk for too-small babies. The authors suggested that there may need to be a threshold of a minimum weight gain, even for very high-BMI women, which is a pretty radical suggestion given how many doctors are calling for zero gain or weight loss in this group.

But these new studies are far from the first to find reasons for concern. A brand-new meta-analysis (Xu 2017) of studies on weight gain below the 2009 guidelines in obese mothers found that low weight gain was associated with SGA babies in all obesity categories, not just in the borderline categories.

Yet another meta-analysis (Kapadia 2015) of studies on weight gain in obese pregnant women concluded that, because of its consistent association with too-small babies,

Gestational weight gain below the guidelines cannot be routinely recommended.

Too-small babies and prematurity may not be the only risks of very low weight gains; they may also be implicated in infant deaths.

A recent study (Bodnar 2016) found that weight loss and very low weight gains in Class I and II obese women were associated with a higher risk of infant death.

This is particularly important because research is very clear that SGA babies have a higher risk for stillbirth and neonatal mortality. In addition, some past research (Salihu 2009) shows that SGA babies of obese women are at particular risk for stillbirth.

Sorry, but SGA babies, prematurity, and infant death are pretty significant concerns. People like Dr. Myles, Dr. Oken, Dr. Stevens, and Dr.Klipstein who have been recommending weight gains well below the IOM recommendations have been playing Russian Roulette with the babies of their patients of size.

This is a common problem in medicine ─ taking a recommendation to extreme lengths without adequately studying its safety first.

Obese women as a group may benefit from gaining less weight on average than other women, but it does NOT automatically follow that even less is better. 

Sadly, while now there are years of data suggesting harms with very low gains and/or gestational weight loss, many experts are STILL telling women of size and their providers that "any weight gain in overweight and obese patients is detrimental to pregnancy outcome." Any weight gain, really?

This bias towards ever-lowered weight gain goals is so ingrained that it continues to deny the existence of any contrary evidence. The 2013 article quoted above advises OB-GYNs:

Weight maintenance and even weight reduction have not proven harmful in obese pregnant patients according to studies in the recent literature

Not proven harmful? This statement completely ignores numerous studies published before 2013 pointing out safety concerns with this advice (Bayerlein 2011, Bodnar 2010, Blomberg 2011, Vesco 2011, Dietz 2006, Potti 2010, Hasegawa 2012).

And now we have EVEN MORE studies showing that there are safety concerns, yet this low/no gain/weight loss advice continues to be given routinely by many providers who assure their patients falsely that there is no reason to worry.

But What About....?

Critics will undoubtedly point out that some of these same studies show benefits of lower gains such as a modestly lower cesarean rate or lower rates of pre-eclampsia. These are valid points. However, that's a whole different discussion because multiple variables influence these complications and it's difficult to tease out a causal relationship.

For example, caregivers are not blinded to their patients' gains. A bigger gain may mean a bigger baby. Fear of a big baby can strongly influence the perception of when a cesarean is "needed" and how many interventions like induction are used. Research shows that women with larger weight gains are induced at higher rates. Therefore it may not be weight gain that's the issue, but rather how the caregiver responds to the gain.

Pre-eclampsia is another situation where you can't jump to conclusions about weight gain. Women with pre-eclampsia typically have a lot of swelling, which means a higher weight gain. 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, a higher weight gain doesn't necessarily cause pre-eclampsia, but rather it often results from pre-eclampsia. It certainly doesn't mean that a lower weight gain will prevent pre-eclampsia. We just don't know if deliberately restricting weight gain will lower the rate of pre-eclampsia in obese women.

However, it must be acknowledged that too much weight gain is probably also not ideal. Prenatal weight gain clearly influences fetal size, and higher gains seem particularly particularly potent for larger fetal size in high-BMI women. Postpartum, a larger gain may also be difficult to lose; multiple pregnancies with large gains can result in a net overall weight increase that might possibly affect the mother's health. So doctors have to find a balance between the very real risk/benefit trade-offs of too much or too little gain in pregnancy.

That's not easy, and I acknowledge that. But it seems to me that the debate is still very unbalanced, with too many experts still not willing to acknowledge the very real risks of too-small gains.

Deliberately ignoring contrary research is not an evidence-based approach. It smacks of a weight restriction agenda instead of a reasoned approach to best practices.

Summary

For too long, "experts" have been waging a campaign to lower the 2009 IOM guidelines even further for obese women. As a result, many care providers have used draconian pressure on women of size to gain very little or even to lose weight in pregnancy. But there are significant safety concerns with this approach, concerns that these so-called experts are conveniently ignoring.

The research makes several things clear:

1. Very low weight gain or weight loss is extremely consistent with too-small babies in multiple studies 
2. Too-small babies are at increased risk for adulthood diseases
3. Weight loss and very low weight gains may also be associated with a higher risk for infant death and prematurity 

These concerns means it's time for caregivers to STOP promoting extreme weight gain limits and to START acknowledging that very low gains also carry risks. 

Now, it may be that in time, different weight gains will be recommended for different levels of obesity. That seems like a possibility that is worthy of further consideration.

For example, "overweight" women (BMI 25-29) and women with Class I obesity (BMI 30-35) seem to be the most negatively affected by very small weight gains, whereas some research shows that women with Class III obesity (BMI 40-50) and Class IV obesity (BMI 50+) are less affected on average by very low gains.

So there may be some gradations in recommendations in the future, and I welcome discussions about this possibility ─ but given the established risks and the meta-analysis of studies that showed increased SGA risks across all class sizes of obesity, it would still behoove us to be very cautious about recommending very low weight gain even in women with Class III and IV obesity. We simply cannot assume that restricting gains is harmless even there.

Common Sense Recommendations

To me, what's missing from prenatal weight gain recommendations for obese women is nuance. It's time to pull back from prenatal weight gain extremism and show some common sense. Here are the things I think caregivers should take into account when discussing pregnancy weight gain with women of size.

Women of size should be informed in a neutral way of the IOM weight gain recommendations and why they were made. A neutral discussion, with research citations as appropriate, goes a lot further to helping women make informed and empowered decisions. A decision about weight gain goals that comes from the woman herself, rather than being imposed by external forces, is a lot more likely to result in reasonable gains.

How the message is communicated is important. Women should be given reasonable nutritional advice and strongly encouraged to exercise, but risks should not be exaggerated. Lecturing, scare tactics, and condescension means that people will simply tune out recommendations. Treat women as competent partners in their own care and avoid judgment. Emphasize healthy habits rather than numbers on the scale.

Consider tailoring recommendations by BMI. Women in the borderline BMI classes are the most at risk for poor outcomes with very low gains; they should be encouraged to gain nearer to the top of the IOM recommendations. It may even be that women with Class I obesity (BMI 30-35) do best with slightly more gain (15-25 lbs.). Women in Class III (BMI over 40) and Class IV obesity (BMI over 50) can be encouraged to gain towards the lower end of the recommendations or even slightly lower (5-15 lbs.) but great care should be taken that this message does not translate into pressure for restricted intake or extreme measures. Do not assume that very high BMI women have adequate nutritional reserves to make up for a lack of gain; good nutrition is always the priority.

Do not promote actively losing weight in pregnancy. Research shows there are too many potential harms to recommend pursuing gestational weight loss. Some women of size lose without trying; this is not a cause for panic as long as intake is adequate and the baby is growing well. But actively encouraging women to aim for weight loss during pregnancy is different than coincidental weight loss, is likely to result in restrictive behaviors, and probably has far greater risk.

Consider patterns of gestational weight gain. Has the weight gain pattern been relatively smooth? Was there a very large gain in the beginning? At the end? Different patterns may indicate different concerns. Also, don't forget to take pre-conception weight into account; many obese women lose weight in the first trimester and slowly gain that back to a small overall gain. If the initial loss is not counted, it looks like the woman has gained more weight than she actually has. Look at the whole picture.

Do not harass women about weight gain. Weight-related harassment is obnoxious and inappropriate, but it is sadly all too common. Women should not feel afraid to step on the scale at appointments, yet they often experience harassment. Medical assistants should record weight without comment. Care providers can ask neutrally about gains and can work with women on monitoring nutrition and troubleshooting worrisome trends, but judgment and belittling will only backfire. If a woman gains outside of guidelines despite good nutrition and regular exercise, consider other possible variables. Assume that a woman's body will gain what it needs for a healthy pregnancy.

Avoid food extremism. Women of size should not be pressured to strongly restrict calories or to eliminate entire food groups. They should be encouraged to eat reasonable amounts from a wide variety of foods. Nutritional advice should be evidence-based, not from unproven diet trends. Caregivers need to find a way to talk to clients about nutrition and weight gain concerns without condescension or judgment. Work with women and listen to their feedback about their needs.

Individualize care according to the woman's needs. People of size are not all alike. Some fit stereotypical images of fast food consumption and binge eating, others have very healthy habits, and many fall somewhere in between. Ask them respectfully about their habits and concerns; don't make assumptions. Believe what they tell you and advise them accordingly. If habits need improvement, encourage small and reasonable steps and recognize positive achievements.

Remember that weight gains among high-BMI women are highly variable. Research shows that weight gains in pregnancy are less predictable in larger women. Some have very large gains, some have very small gains, and some lose weight without trying. Often the women who gain the most are those who have recently lost weight or who are chronic dieters/weight cyclers, those with lipedema, or those who have swelling with pre-eclampsia. Many factors influence gestational weight gain besides the habits of the women. Acknowledge that some weight gain may be out of their control.

Look more at how the mother and baby are doing than at the scale. Guidelines are more for groups than individuals. While research shows that very high or very low gains are generally best avoided on average, some obese women gain more or less than recommended and have perfectly healthy babies. Some gain a lot and have average-sized babies; some gain almost nothing and have big babies; some lose weight with no obvious harmful effect. Gaining outside the recommendations is not necessarily a cause for alarm, as long as the mother's intake is normal and baby is growing well.

Women should not be subjected to extra interventions if they exceed their providers' weight gain goals. Some fat women are being consciously punished for "too much weight gain" by being subjected to extra interventions like inductions or planned cesareans. However, some of these interventions may occur because of providers' underlying fears about big babies. Care providers must actively examine their own biases so that they do not unconsciously use increased interventions on those who gain more.

Most importantly, focus on nutrition rather than on the scale. Too many providers use weight gain as a marker of pregnancy status and ignore nutrition altogether. What a woman is eating matters more than how much weight she has gained. Women can be given a weight gain goal range, nutritional advice, and exercise opportunities, but nutrition should not be manipulated in order to achieve an arbitrary number. The scale is a poor predictor of outcome and should not be used as a surrogate for nutritional adequacy or fetal status. Focus more on nutrition and concrete signs of how the mother/baby dyad is doing than on numbers on a scale.

Care providers need to bring common sense back into prenatal weight gain guidelines and take a more nuanced approach with women of size.


References

Very Low Gain and Too-Small Infants (Latest Studies)

Am J Perinatol. 2016 Jun 29. [Epub ahead of print] Gestational Weight Gain: Association with Adverse Pregnancy Outcomes. Hannaford KE1, Tuuli MG, Odibo L, Macones GA, Odibo AO. PMID: 27355980 DOI: 10.1055/s-0036-1584583

...OBJECTIVES: We investigated how weight gain outside the IOM's recommendations affects the risks of adverse pregnancy outcomes. STUDY DESIGN: We performed a secondary analysis of a prospective cohort study including singleton, nonanomalous fetuses. The risks of small for gestational age (SGA), macrosomia, preeclampsia, cesarean delivery, gestational diabetes, or preterm birth were calculated for patients who gained weight below or above the IOM's recommendations based on body mass index category....Women who gained weight below recommendations were 2.5 times more likely to deliver SGA and twice as likely to deliver preterm...Obese patients who gained inadequate weight were 2.5 times more likely to deliver SGA. CONCLUSIONS: ...Among obese patients, a minimum weight gain requirement may prevent SGA infants.

Am J Perinatol. 2016 Jul;33(9):849-55. doi: 10.1055/s-0036-1579650. Epub 2016 Mar 9. Impact of Gestational Weight Gain on Perinatal Outcomes in Obese Women. Durst JK, Sutton AL, Cliver SP, Tita AT, Biggio JR. PMID: 2696070

...STUDY DESIGN: A retrospective cohort of perinatal outcomes in obese women who gained below, within, or above the 2009 Institute of Medicine guidelines and delivered ≥ 36 weeks. Additionally, outcomes, according to the rate of GWG (kg/week; minimal [< 0.16], moderate [0.16-0.49], or excessive [> 0.49]) were compared among women delivering preterm. RESULTS: Overall, 5,651 obese women delivered ≥ 36 weeks. GWG above guidelines was associated with increased cesarean section (adjusted odds ratio [aOR]: 1.44, 95% confidence interval [CI]: 1.21-1.72), gestational hypertension (aOR: 1.58, 95% CI: 1.21-2.06), and macrosomia (birth weight ≥ 4,000 g) (aOR: 2.08, 95% CI: 1.62-2.67). GWG below recommendations was associated with less large for gestational age infants (aOR: 0.60, 95% CI: 0.47-0.75)...Minimal weekly GWG was associated with increased spontaneous preterm birth (aOR: 1.56, 95% CI: 1.23-1.98) and more small for gestational age (SGA) infants (aOR: 1.55, 95% CI: 1.19-2.01). Excessive weekly GWG was associated with increased indicated preterm birth (aOR: 1.61, 95% CI: 1.29-2.01), cesarean section (aOR: 1.39, 95% CI: 1.20-1.61), preeclampsia (aOR: 1.83, 95% CI: 1.49-2.26), neonatal intensive care unit admission (aOR: 1.33, 95% CI: 1.08-1.63), and macrosomia (aOR: 2.40, 95% CI: 1.94-2.96).CONCLUSIONS: Obese women with excessive GWG had worse outcomes than women with GWG within recommendations. Limited GWG was associated with increased spontaneous preterm birth and SGA infants.

J Perinatol. 2016 Apr;36(4):278-83. doi: 10.1038/jp.2015.202. Epub 2016 Jan 7. Maternal and neonatal outcomes in obese women who lose weight during pregnancy. Cox Bauer CM, Bernhard KA, Greer DM, Merrill DC. PMID: 26741574

OBJECTIVE: To evaluate neonatal and maternal outcomes in obese pregnant women whose weight gain differed from the Institute of Medicine (IOM) recommendations. STUDY DESIGN: Maternal and neonatal outcomes associated with weight change in pregnancy were retrospectively investigated in women with obesity (body mass index (BMI) ⩾30 kg m(-2); N=10734) who gave birth at 12 hospitals...RESULT: Compared with IOM recommendations, weight loss was associated with twofold greater odds of low birth weight infants and a mean decrease in estimated blood loss of 30 ml; excessive weight gain was associated with doubled odds of gestational hypertension or preeclampsia, fourfold greater odds of macrosomia and a mean decrease in 5-min APGAR of 0.09....

J Matern Fetal Neonatal Med. 2017 Feb;30(3):357-367. Epub 2016 Apr 28. Inadequate weight gain in obese women and the risk of small for gestational age (SGA): a systematic review and meta-analysis. Xu Z, Wen Z, Zhou Y, Li D, Luo Z. PMID: 27033234

...We conducted a meta-analysis of original researches with sufficient information about inadequate GWG in obese women stratified by obesity classes. SGA as the chief outcome was extracted and assessed in our analysis...13 studies (437 512 obese women) were included. Obese women who gained weight below the guidelines had higher risks of SGA than those who gained weight within the guidelines (OR 1.28; 95% CI 1.14-1.43). The same conclusions were also confirmed in Class I, Class II and Class III of obese women: Class I (OR 1.37; 95% CI 1.22-1.54); Class II (OR 1.38; 95% CI 1.24-1.54); Class III (OR 1.25; 95% CI 1.14-1.36). CONCLUSIONS: From our analysis, the guidelines of IOM can be applied to all the classes of obesity. More accurate boundaries for each obesity class should be established to evaluate the maternal and fetal risks. Diverse populations are thus necessary for more studies in the future.

Low Weight Gain/SGA and Risk for Infant Death 

Obesity (Silver Spring). 2016 Feb;24(2):490-8. doi: 10.1002/oby.21335. Epub 2015 Nov 17. Maternal obesity and gestational weight gain are risk factors for infant death. Bodnar LM, Siminerio LL, Himes KP, Hutcheon JA, Lash TL, Parisi SM, Abrams B. PMID: 26572932

OBJECTIVE: Assessment of the joint and independent relationships of gestational weight gain and prepregnancy body mass index (BMI) on risk of infant mortality was performed. METHODS: This study used Pennsylvania linked birth-infant death records (2003-2011) from infants without anomalies born to mothers with prepregnancy BMI categorized as underweight (n = 58,973), normal weight (n = 610,118), overweight (n = 296,630), grade 1 obesity (n = 147,608), grade 2 obesity (n = 71,740), and grade 3 obesity (n = 47,277)...For all BMI groups except for grade 3 obesity, there were U-shaped associations between gestational weight gain and risk of infant death. Weight loss and very low weight gain among women with grades 1 and 2 obesity were associated with high risks of infant mortality....

Am J Perinatol. 2016 Aug 17. [Epub ahead of print] Morbidity and Mortality in Small-for-Gestational-Age Infants: A Secondary Analysis of Nine MFMU Network Studies. Mendez-Figueroa H1, Truong VT2, Pedroza C2, Chauhan SP1. PMID: 27533102

...Data from nine Maternal-Fetal Medicine Units Network studies were used and included nonanomalous singletons at 24 weeks or more and birth weight < 90% for EGA...Among SGA, the likelihood of stillbirth (8.8 vs. 2.5 per 1,000 births; adjusted odds ratio [aOR] 3.98, 95% confidence interval [CI]: 2.92-5.42) and neonatal mortality (14.0 vs. 5.5 per 1,000 births; aOR 3.18, 95% CI: 2.55-3.95) was threefold higher compared with AGA. For the subgroup of newborns of EGA of 32 weeks or more, SGA, compared with AGA, had significantly higher risk of stillbirth (aOR 3.32, 95% CI: 2.16-5.12) and neonatal mortality (aOR 2.50; 95% CI: 1.38-4.54). From 35 weeks onward, the risk of stillbirth among SGA is almost four times higher than for AGA. CONCLUSION: The risk of stillbirth and neonatal mortality is significantly higher with SGA than with AGA. Modification in practice or new management schema may be warranted.

Obstet Gynecol. 2009 Aug;114(2 Pt 1):333-9. Success of programming fetal growth phenotypes among obese women. Salihu HM, 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)...Neonatal mortality among LGA infants was similar for obese...and normal...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.

Low Weight Gain and Risk for Prematurity

Obesity (Silver Spring). 2013 Dec;21(12):E770-4. doi: 10.1002/oby.20490. Epub 2013 Jul 5. 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

...Retrospective cohort study of 26,205 overweight and obese gestational diabetic women enrolled in the California Diabetes and Pregnancy Program. Women with GWL [Gestational Weight Loss] during program enrollment were compared to those with weight gain...RESULTS: About 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. Further research on weight loss and interventions to improve adherence to weight guidelines in this population is recommended.

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 A, 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.

Epidemiology. 2006 Mar;17(2):170-7. Combined effects of prepregnancy body mass index and weight gain during pregnancy on the risk of preterm delivery. Dietz PM, Callaghan WM, Cogswell ME, Morrow B, Ferre C, Schieve LA. PMID: 16477257

...METHODS: Using data from the Pregnancy Risk Assessment Monitoring System in 21 states, we estimated the risk of very (20-31 weeks) and moderately (32-36 weeks) preterm delivery associated with a combination of prepregnancy body mass index (BMI) and gestational weight gain among 113,019 women who delivered a singleton infant during 1996-2001...RESULTS: There was a strong association between very low weight gain and very preterm delivery that varied by prepregnancy BMI, with the strongest association among underweight women (adjusted odds ratio = 9.8; 95% confidence interval = 7.0-13.8) and the weakest among very obese women (2.3; 1.8-3.1)...Women with very high weight gain had approximately twice the odds of very preterm delivery, regardless of prepregnancy BMI. CONCLUSIONS: This study supports concerns about very low weight gain during pregnancy, even among overweight and obese women, and also suggests that high weight gain, regardless of prepregnancy BMI, deserves further investigation.

J Matern Fetal Neonatal Med. 2012 Oct;25(10):1909-12. doi: 10.3109/14767058.2012.664666. Epub 2012 Mar 12. Gestational weight loss has adverse effects on placental development. Hasegawa J1, Nakamura M, Hamada S, Okuyama A, Matsuoka R, Ichizuka K, Sekizawa A, Okai T. PMID: 22348351

OBJECTIVE: To clarify whether mothers with gestational weight loss (GWL) were likely to have adverse effects on the placenta. STUDY DESIGN: Subjects who delivered viable singleton infants after 24 weeks of gestation were enrolled. A retrospective analysis to evaluate cases of GWL in association with the findings of the placenta and amniotic membrane after delivery was conducted. After consideration of confounders, a case-control study with matched pairs (1:2) was performed. RESULTS: Of all subjects (5551 cases), 83 cases (1.5%) with GWL were found. Since the pre-pregnancy maternal body mass index (BMI) was significantly higher in cases, 166 controls with a matched BMI were selected. The neonatal birth weights, placental weights and the umbilical cord length in cases were significantly smaller than in controls (p < 0.05). Preterm delivery and small for gestational age (SGA) infants were more frequently observed in cases compared with controls [odds ratio (OR) 6.3; 95% confidence interval (CI) 3.3, 12.1, OR 4.3; 95% CI 1.9, 9.9]. pPROM were observed in 10.8% of the cases and 1.8% of the control (OR 6.6; 95% CI 1.7, 25.1). However, the frequencies of chorioamnionitis and the cervical length at second trimester were not different between the two groups. CONCLUSION: GWL is associated with SGA, small placenta, short umbilical cord length, preterm delivery and pPROM.

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.

Conclusions

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. 

Restricting Prenatal Weight Gain Does Not Make for Skinnier Children

Many care providers promote restricting prenatal weight gain in "obese" women with the hopes that this will reduce obesity in their offspring.

Keep fat women from gaining weight in pregnancy and you will keep their children from being fat, right? "Do it for the children!" is the guilt-inducing line.

Here is a recent study that shows that prenatal weight gain restriction does not have any effect on child size.


Reference

Child Obes. 2016 Jun;12(3):162-70. doi: 10.1089/chi.2015.0177. Epub 2016 Mar 23. Effects of a Gestational Weight Gain Restriction Program for Obese Pregnant Women: Children's Weight Development during the First Five Years of Life. Claesson IM1, Sydsjö G1, Olhager E2, Oldin C3, Josefsson A1. PMID: 27007580

BACKGROUND: Maternal prepregnancy obesity (BMI ≥30 kg/m(2)) and excessive gestational weight gain (GWG) have shown a strong positive association with a higher BMI and risk of obesity in the offspring. The aim of this study is to estimate the effect of a GWG restriction program for obese pregnant women on the children's BMI at 5 years of age and weight-for-length/height (WL/H) development from 2 months of age until 5 years of age. METHODS: This was a follow-up study of 302 children (137 children in an intervention group and 165 children in a control group) whose mothers participated in a weight gain restriction program during pregnancy. RESULTS: BMI at five years of age did not differ between girls and boys in the intervention and control group. The degree of maternal GWG, <7 kg or ≥7 kg, did not affect the offspring's WL/H. Compared with Swedish reference data, just over half of the children in both the intervention and control group had a BMI within the average range, whereas slightly more than one-third of the children had a higher BMI. CONCLUSION: Despite a comprehensive gestational intervention program for obese women containing individual weekly visits and opportunity to participate in aqua aerobic classes, there were no differences between BMI or weight development among the offspring at 5 years of age in the intervention and control group.

Diet and Exercise No Cure for Obesity

A recent article (written by weight-loss doctors, no less) finally pointed out what we have been saying for so long ─ that very few fat people actually lose weight and keep it off successfully long-term, that it's NOT just about eating less and moving more, and that the body actually has biological mechanisms that work very strongly against weight loss efforts. Here's a quote:

A group of respected physicians has stepped forward to challenge the common assertion that obesity can be easily fixed by diet and exercise. 

For most of the nation’s 79 million adults and 13 million kids who are obese, the “eat less, move more” treatment, as currently practiced, is a prescription for failure, these doctors say.

In a commentary published Thursday in the journal Lancet Diabetes and Endocrinology, four weight-loss specialists set out to correct what they view as the widespread misimpression that people who have become and stayed obese for more than a couple of years can, by diet and exercise alone, return to a normal, healthy weight and stay that way. 

...The depressing fact, said Ochner in an interview, is that “the average adult with sustained obesity has less than a 1 percent chance of reattaining and maintaining a healthy body weight without surgery...What really bothers me working around and with clinicians, is that some of them — a disturbing percentage — still believe it’s all about personal choice: that if the patient just tries hard enough, and if we can just figure out how to get them a little more motivated, then we’d be successful. And that’s just not right.”

Of course, this commentary was not perfect, naturally. The authors seem to assume that all fat people are average-sized people who only get fat over time, ignoring the many people who have higher-BMIs consistently throughout their whole lives (suggesting genetic and metabolic mechanisms). And because of this, they still called on doctors to intervene more stringently among "overweight" patients in hopes of preventing them from becoming "obese," and to aggressively use weight-loss surgery, medications, and devices with obese people to get that weight down. (Sounds like WLS surgeons trying to increase business, frankly. And it conveniently ignores the fact that it's weight loss interventions and pressure on "overweight" and Class I "obese" patients that often lead to more obesity rather than less.)

But it was refreshing to hear doctors admit what we have known for so long, that it's not just about eating less and exercising more, that success with permanent weight loss is extremely unlikely, and that the bias of what doctors want to believe about fatness is increasing stigma and inhibiting actual good care of these people.