Canning Books for Beginners

Image by Carter Housh

It's that time of year, when all the bounty of summer fruits are starting to roll in. Strawberries are in, rhubarb is in, the raspberries have just sprung to fruition, and cherries are hitting full force. Blueberries are just around the corner, and then it's time for plums. Yummm!

For me, that means it's time to start canning in order to preserve all these delicious fruits so I can enjoy them next winter too.

This is not something I grew up doing or learned from my mother; I had to learn it on my own. I came to it only in middle age, but it's a skill I'm determined to teach all my children because I think it's something everyone should know how to do.

If for no other reason, people should know how to preserve food so they have some emergency food on hand that doesn't depend on a refrigerator or freezer to keep it safe. And of course it's great to have these summer foods available to eat out of season, and they make great homemade gifts. But the best reason is because these foods just taste delicious!

So let's talk about the very easiest foods to can, jams and preserves, and the best books for learning how to prepare these.

Canning Books for Jams

When I was first learning how to can, I looked for a book that was quick and easy to understand, had great diagrams and instructions, and which had a lot of interesting recipes.

I found quite a number of good canning books and resources out there. Each one had something different to recommend it. Here are the best ones for beginners.

Put 'Em Up by Sherri Brooks Vinton is my favorite canning book and the one I recommend to beginners. I find the explanations very clear and concise, with some of the most clear illustrations of the process I've seen. When I was a beginner, this was the book that was most helpful to me.

I also liked that she organized the book by types of produce, so if cherries are in season and you are looking for something new to do with your overload of fresh cherries, you just turn to the "cherry" section of the book (which is clearly labeled and easy to find). That is really helpful. Many canning books are not organized like this.

The author has a great sequel too, just for fruits, with further recipes and hints on how to use them. And she now has a Preserving Answer Book, to answer common questions about canning, drying, freezing, etc. for those fairly new to food preservation.

One of the most common canning books, of course, is the Ball Blue Book Guide to Preserving and the Ball Complete Book of Home Preserving. Its companion website is www.freshpreserving.com, and it has a great guide to getting started with canning if you want to learn about canning without having to spend the money to buy a book.

This book is the classic canning book, and all its recipes have been extensively tested for safety. It's been around forever so it's got lots of time-tested recipes that have been favorites for generations. It goes far beyond the basic jam recipes included in most books and has recipes for many other types of foods besides jams.

A newer canning book that many people seem to like is Food In Jars by Marisa McClellan. The author has an excellent blog from which the book sprang. It has lots of interesting hints for canning and links to unusual products like special canning jars.

One interesting thing about Food In Jars recipes is that they often have unusual flavor combinations that go beyond the usual basic recipes found in most books. She typically does not use pectin in her recipes, but teaches the old-fashioned cook-em-till-they-set method. She has a great Canning 101 section on her blog where she answers a lot of questions about canning technique and safety.

The author has also written Preserving By The Pint, which specializes in canning recipes for very small batches, which can seem more do-able to the beginning canner since no special equipment and no huge pots of water are needed. You don't need to buy big batches of fruit and you end up with only a few jars to store, which is important if you have only limited storage. Most canning recipes were written for women with large families to feed; this is the scaled-down version for folks with very small families, not much time, or limited storage.

Another bonus is that the author does a lot of touring and offers classes all over the country teaching many of the recipes used in her book. That's good marketing and it helps a lot of people who feel insecure with canning to get past the fear and start doing it.

Another book which might be really handy for some is Preserving with Pomona's Pectin by Allison Carroll Duffy. This book specializes in recipes using Pomona's Pectin, which is a somewhat harder-to-find pectin but which offers the distinct advantage of being able to adjust the sugar content in a recipe.

With most other pectins, you have very little flexibility about how much sugar to use in a recipe. The full-sugar pectins use insane amounts of sugar in their recipes; usually far more sugar than fruit. Even the "reduced sugar" pectins (like Sure-Jell in the pink box) still use quite a bit of sugar.

But Pomona's Pectin works differently than other pectins. It doesn't need sugar to help "gel" the jam; it uses calcium water instead to get the gel. This means that the sugar content of these jams can be adjusted to your heart's content. You can use as much or as little as you prefer, and you can use honey, agave syrup, fruit juice, or artificial sweeteners to sweeten your jam instead of sugar. If you are one of the many people trying to reduce the sugar content in your diet for health reasons, this is a great option to have.

Pomona's Pectin offers a lot more flexibility than other pectins, but it has a little steeper learning curve than the full-sugar pectins. Having a book that discusses the process of using this pectin in minute detail can be useful for those new to canning with Pomona's Pectin.

Summary

There are many, many great canning books available out there, but these are some of the best canning books for beginners. Youtube also has many video tutorials available on canning, and you can find many canning instructional DVDs as well.

Once you get good at the basics, then you can start adding wet and dry "zing" (spices and liqueurs) to your fruit ingredients and creating your own custom recipes. Or you can learn how to make pectin-free jams. But first, it's helpful to get comfortable with the fundamentals.

There are so many great resources on learning to can out there; get started on learning this important skill this summer! Or take your basic knowledge of canning to a whole new level of experimentation instead by playing around with the more advanced recipes in these books and blogs.

Remember, it's perfectly okay not to be a Canning Diva; you're not a canning failure if you don't spend all your time in the kitchen or put up great quantities of food. Do as much or as little canning as you have time for, but do learn to can so we keep this important skill alive and so that you have shelf-stable food put aside for emergencies. 

Breastfeeding And Gestational Diabetes, Part One: Vital Benefits to Mother and Baby

More and more research is showing how important breastfeeding is after a Gestational Diabetes (GD) pregnancy, both for mother and baby.

Yet research consistently also shows lower rates of breastfeeding after Gestational Diabetes.

Promoting and improving breastfeeding rates in GD mothers is one easy way to improve the long-term health of mothers and babies exposed to GD, yet there are still far too many barriers to it.

Let's start with the many benefits of breastfeeding after GD, both for mother and baby.

How Breastfeeding Helps After Gestational Diabetes

Image credit: Much 2014

Breastfeeding improves the mother's blood sugar and insulin levels very quickly post-partum, and improves glucose utilization. It may also improve pancreatic beta cell mass, proliferation, and function, which should improve the mother's capacity to produce insulin adequate to compensate for any insulin resistance.

GD women who breastfeed have lower rates of abnormal blood sugar at their 6-week follow-up glucose tolerance test postpartum.

Breastfeeding also lowers insulin levels and improves insulin sensitivity more long-term.

As a result, breastfeeding lowers a mother's risk for developing diabetes later in life.

Even only a short period of breastfeeding offers some protection. However, the more you breastfeed and the longer the duration, the more your risk for diabetes may be diminished. That's HUGE.

Image credit: Much 2014, adapted from Ziegler 2012

Look at the graph above. Although many women were lost to follow-up, there was a clear and strong trend towards less diabetes in the women who breastfed their babies for more than three months. 72.6% of those who did not breastfeed or who breastfed for three or fewer months developed diabetes by 15 years post-partum, vs. 42% of those who breastfed for more than three months.

And really, three months of breastfeeding isn't that long in the scheme of things. Studies that looked at moderately longer periods found much lower insulin levels and better insulin sensitivity in those that nursed more than 10 months.

And 10 months does not even meet the American Academy of Pediatric's recommendation to nurse at least a year, or the World Health Organization's recommendation to nurse at least two years. How much more protection might there be for longer periods of breastfeeding?

One very large 2005 study found that the risk for diabetes declined about 15% for each additional cumulative year of breastfeeding, and another 2008 study found that the relative risk for diabetes was 0.68 in those with 4 or more years of lifetime lactation duration.

Breastfeeding may also offer some degree of protection against certain types of cancer which GD mothers may be more at risk for, including breast, endometrial, ovarian and possibly pancreatic cancers.

Even more imporantly, long-term breastfeeding may also offer some protection against heart disease and mortality. 

Some studies have found lower rates of cardiovascular risk factors in women with long-term breastfeeding. Most importantly, research has shown that breastfeeding translates into fewer heart attacks and lower mortality rates too. That's also HUGE.

One theory to explain all this is that pregnancy induces temporary changes in glucose and lipid metabolism that are beneficial for baby but not for the mother, and that these changes are even more marked in women with Gestational Diabetes. In this theory, breastfeeding is nature's way of "re-setting" the mother's metabolism back to normal afterwards. If breastfeeding does not occur (or is brief), the mother's metabolism doesn't really return to normal and she is much more likely to develop diabetes, hypertension, and heart disease with time.

Although this is still just a theory at this point, it is a logical one, and one with some data to support its premise. Obviously, the human body is complex and many different factors play a role in the development of disease, but long-term breastfeeding may be an effective, low-cost, and extremely practical way to lower the risk for later disease.

Clearly, breastfeeding (and especially long-term breastfeeding) has important potential benefits for GD mothers.

Extra Benefits for GD Babies

Breastfeeding has so many benefits for all babies. We've known this for quite a while, yet it's surprising how often this does not get communicated well to pregnant women or the general public.

The general benefits of breastfeeding include lower risk for infections, asthma, diarrhea, ear infections, celiac disease, Sudden Infant Death Syndrome (SIDS), necrotizing enterocolitis in pre-term infants, and many other things. That's all pretty important right there.

But breastfeeding has extremely important immunological functions that are under-appreciated even among care providers. When in utero, the baby depends on the mother's placenta for immunological protection. After the baby is born, its own immunological system is quite immature. Nature designed breastfeeding to help bridge the gap between in utero protection and when the baby's own immunological system matures.

The first milk, colostrum, plays a vital role in "coating" the surface of the baby's intestines to help them be less vulnerable to pathogens. Later, human milk encourages the growth of the villi in the intestine and develops antibody responses specific to the pathogens the mother encounters. It also helps the baby strengthen and develop its own immuno-responses to pathogens, which may provide enhanced immuno-protection even after breastfeeding ends. Thus, breastfeeding is crucial in protecting the baby's immune system both short- and long-term. Its benefits do not end with weaning.

These are all important reasons to raise breastfeeding rates in the general population. However, there are additional potential benefits for babies of GD pregnancies.

The biggest benefit of breastfeeding after a GD pregnancy is that it lowers the risk of the baby developing diabetes as he/she grows to adulthood.

This is another HUGE advantage. Babies exposed to higher blood sugar rates in utero tend to have poorer glucose metabolisms, more insulin resistance, and more metabolic syndrome later in life.

If breastfeeding can prevent or delay many cases of metabolic syndrome and diabetes in a GD mother's offspring, it has tremendous public health implications for babies as well as mothers.

And this may be a particularly important finding for people of color, because of their increased risk for diabetes. One early study in a particularly vulnerable population (Pima Indians) found about half the risk for diabetes in adults who were breastfed for at least two months compared to those who were not. Imagine what the difference might be with longer periods of breastfeeding!

One study projected that if 90% of families in the U.S. breastfed exclusively for 6 months, about 911 deaths would be prevented each year. Of course, data projections like this are merely speculative, but even so, a clear trend in the statistical model implies that increasing breastfeeding rates would be a low-cost, effective strategy for improving public health in babies as well as in mothers.

And this may especially be true for babies of GD pregnancies.

Conclusion

Breastfeeding is a vital part of the so-called "fourth trimester" of pregnancy...and well beyond.

In other words, the mother's biological role in protecting her baby does not end with the baby's birth. It extends into breastfeeding and even beyond weaning.

Nature intended babies to be breastfed for significant periods of time in order to protect them while they are immunologically immature and to produce optimal and healthy growth and development. Nature also intended breastfeeding to benefit the mother by re-setting her metabolism and lowering her risk for heart disease and some cancers. Breastfeeding's benefits to both baby and mother do not end with weaning but appear to last for years afterwards.

Obviously, there are times when breastfeeding isn't possible, doesn't work out, or isn't wanted for various reasons, and it's good that we have substitutes available for these situations. Formula isn't "bad" or "evil," and it's a reasonably good substitute when human breastmilk is not available. Although uncommon, there are women who are truly unable to breastfeed and it's important that we have respect for that experience and support for those women even as we promote breastfeeding.

However, we must remember that Nature's design results in the most optimal outcomes and we subvert that design at the risk of significant harm on a population-wide basis. 

How much of our public health woes today are due to the widespread and very strong discouragement of breastfeeding by physicians in the last century? We may never know, but I would bet that at least some of the increase in diabetes and other problems we see today is at least partly due to the tremendous pressure on women from the mid-20th century not to breastfeed.

Even today, when most care providers at least pay lip service to the benefits of breastfeeding, many women are subtly discouraged from nursing or are told that there is little benefit to continuing to breastfeed past a few months. (Yep, I heard this one).

Even more alarming, despite evidence of EXTRA benefits to breastfeeding after a GD pregnancy, women with Gestational Diabetes have lower rates of breastfeeding than other women. 

Although some of this may have some basis in biological differences like PCOS (Polycystic Ovarian Syndrome), much of it is rooted in routine practices and interventions common during and after births in women with Gestational Diabetes. Yet care providers often fail to recognize that breastfeeding "failure" often begins with the interventions that occur during and after birth. 

There is much that can be done to raise breastfeeding rates in women with GD, if only caregivers and hospitals would recognize the role that common interventions plays in interfering with establishment of breastfeeding.

That's not to say that interventions should never take place. Sometimes interventions are truly necessary, especially in complicated cases of GD, but the reality is that they are often overused, and reducing them is a good first step in increasing breastfeeding rates. And even when interventions are truly necessary, there is much that can be done to protect and promote breastfeeding under less than ideal conditions, yet full implementation of these measures is lacking in many hospitals.

In our next post, we will discuss specifics on how to remove barriers and raise breastfeeding rates in women with GD. For the long-term health of babies and mothers, it is critical that we do this.


References

Breastfeeding and Short-Term Maternal Glucose Tolerance

Ir Med J. 2012 May;105(5 Suppl):31-6. Breast-feeding is associated with reduced postpartum maternal glucose intolerance after gestational diabetes. O'Reilly M, Avalos G, Dennedy MC, O'Sullivan EP, Dunne FP. PMID: 22838108

...We prospectively examined the prevalence of postpartum dysglycaemia after GDM and examined the effect of lactation on postpartum glucose tolerance. We compared postpartum 75g oral glucose tolerance test (OGTT) results from 300 women with GDM and 220 controls with normal gestational glucose tolerance (NGT). Breast-feeding data was collected at time of OGTT...The prevalence of persistent hyperglycaemia was significantly lower in women who breast-fed versus bottle-fed postpartum (8.2% v 18.4%, p < 0.001). Breast-feeding may confer beneficial metabolic effects after GDM and should be encouraged.

Diabetes Care. 2012 Jan;35(1):50-6. doi: 10.2337/dc11-1409. Epub 2011 Oct 19. Lactation intensity and postpartum maternal glucose tolerance and insulin resistance in women with recent GDM: the SWIFT cohort. Gunderson EP, Hedderson MM, Chiang V, Crites Y, Walton D, Azevedo RA, Fox G, Elmasian C, Young S, Salvador N, Lum M, Quesenberry CP, Lo JC, Sternfeld B,Ferrara A, Selby JV. PMID: 22011407

OBJECTIVE: To examine the association between breastfeeding intensity in relation to maternal blood glucose and insulin and glucose intolerance based on the postpartum 2-h 75-g oral glucose tolerance test (OGTT) results at 6-9 weeks after a pregnancy with gestational diabetes mellitus (GDM). RESEARCH DESIGN AND METHODS: We selected 522 participants enrolled into the Study of Women, Infant Feeding, and Type 2 Diabetes (SWIFT), a prospective observational cohort study of Kaiser Permanente Northern California members...RESULTS:...Exclusive or mostly breastfeeding groups had lower prevalence of diabetes or prediabetes (P = 0.02). CONCLUSIONS: Higher intensity of lactation was associated with improved fasting glucose and lower insulin levels at 6-9 weeks' postpartum. Lactation may have favorable effects on glucose metabolism and insulin sensitivity that may reduce diabetes risk after GDM pregnancy.

Obstet Gynecol. 2012 Jul;120(1):136-43. doi: 10.1097/AOG.0b013e31825b993d. Influence of breastfeeding during the postpartum oral glucose tolerance test on plasma glucose and insulin.
Gunderson EP, Crites Y, Chiang V, Walton D, Azevedo RA, Fox G, Elmasian C, Young S, Salvador N, Lum M, Hedderson MM, Quesenberry CP, Lo JC, Ferrara A,Sternfeld B. PMID: 22914402

...Participants were enrolled in the Study of Women, Infant Feeding, and Type 2 Diabetes, a prospective observational cohort study of 1,035 Kaiser Permanente Northern California members who had been diagnosed with GDM...RESULTS: Of 835 lactating women, 205 (25%) breastfed their infants during the 2-hour 75-g OGTT at 6-9 weeks postpartum....CONCLUSION: Among postpartum women with recent gestational diabetes mellitus, breastfeeding an infant during the 2-hour 75-g OGTT may modestly lower plasma 2-hour glucose (5% lower on average) as well as insulin concentrations in response to ingestion of glucose.

Breastfeeding and Subsequent Maternal Diabetes

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. RESULTS A total of 3,160 (6.0%) women were classified as having type 2 diabetes. Overall, nulliparous and parous women had a similar risk of diabetes. Among parous women, there was a 14% (95% CI 10-18%, P < 0.001) reduced likelihood of diabetes per year of breastfeeding. Compared to nulliparous women, parous women who did not breastfeed had a greater risk of diabetes (odds ratio 1.48, 95% CI 1.26-1.73, P < 0.001), whereas for women breastfeeding, the risk was not significantly increased. 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.

Diabetes. 2012 Dec;61(12):3167-71. doi: 10.2337/db12-0393. Epub 2012 Oct 15. Long-term protective effect of lactation on the development of type 2 diabetes in women with recent gestational diabetes mellitus. Ziegler AG, Wallner M, Kaiser I, Rossbauer M, Harsunen MH, Lachmann L, Maier J, Winkler C, Hummel S. PMID: 23069624

...To investigate whether breastfeeding influences short- and long-term postpartum diabetes outcomes, women with GDM (n = 304) participating in the prospective German GDM study were followed from delivery for up to 19 years postpartum for diabetes development. All participants were recruited between 1989 and 1999. Postpartum diabetes developed in 147 women and was dependent on the treatment received during pregnancy (insulin vs. diet), BMI, and presence/absence of islet autoantibodies. Among islet autoantibody-negative women,breastfeeding was associated with median time to diabetes of 12.3 years compared with 2.3 years in women who did not breastfeed. The lowest postpartum diabetes risk was observed in women who breastfed for >3 months. On the basis of these results, we recommend that breastfeeding should be encouraged among these women because it offers a safe and feasible low-cost intervention to reduce the risk of subsequent diabetes in this high-risk population. 

Lactation Duration and Subsequent Maternal Diabetes

Eur J Endocrinol. 2013 Mar 15;168(4):515-23. doi: 10.1530/EJE-12-0939. Print 2013 Apr. Relationship between lactation duration and insulin and glucose response among women with prior gestational diabetes. Chouinard-Castonguay S, Weisnagel SJ, Tchernof A, Robitaille J. PMID: 23302255

...The study group comprised 144 women with a history of GDM between 2003 and 2010. Plasma insulin and glucose concentrations were obtained from a 75 g oral glucose tolerance test (OGTT). Total lactation duration (exclusive breastfeeding and breast and bottle-feeding) for all infants was self-reported in months. RESULTS: Mean age was 36.5±5.0 years. Time between delivery and metabolic testing was 4.0±1.9 years. Women breastfed for an average of 13.9±16.8 months. Most women (80.6%) reported a history of lactation...Compared with women who lactated for <10 months, women who lactated for ≥10 months had improved insulin sensitivity-secretion index, higher HOMA-IS and Matsuda indices, lower fasting and 2-h post-OGTT insulin concentrations as well as AUC for insulin, and lower incidence of impaired glucose intolerance (P≤0.05 for all). In multiple linear regression analyses, lactation duration emerged as an independent predictor of fasting insulin concentrations (β=-0.02) and insulin sensitivity indices (β=0.02) (P≤0.05 for all). CONCLUSIONS: These results suggest that longer duration of lactation is associated with improved insulin and glucose response among women with prior GDM.

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. Lactation may reduce risk of type 2 diabetes in young and middle-aged women by improving glucose homeostasis. 

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 Implications

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 T1, 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.

Breastfeeding and Maternal Cancer

Am J Clin Nutr. 2013 Oct;98(4):1020-31. doi: 10.3945/ajcn.113.062794. Epub 2013 Aug 21. Breastfeeding and ovarian cancer risk: a meta-analysis of epidemiologic studies. Luan NN1, Wu QJ, Gong TT, Vogtmann E, Wang YL, Lin B. PMID: 23966430

...We performed a meta-analysis to summarize available evidence of the association between breastfeeding and breastfeeding duration and EOC [ovarian cancer] risk from published cohort and case-control studies...RESULTS: Five prospective and 30 case-control studies were included in this analysis. The pooled RR for ever compared with never breastfeeding was 0.76 (95% CI: 0.69, 0.83), with moderate heterogeneity (Q = 69.4, P < 0.001, I(2) = 55.3%). Risk of EOC decreased by 8% for every 5-mo increase in the duration of breastfeeding (RR: 0.92; 95% CI: 0.90, 0.95). The risk reduction was similar for borderline and invasive EOC and was consistent within case-control and cohort studies. CONCLUSIONS: Results of this meta-analysis support the hypothesis that ever breastfeeding and a longer duration of breastfeeding are associated with lower risks of EOC....

Breastfeeding and Diabetes in Children

Am J Clin Nutr. 2006 Nov;84(5):1043-54. Does breastfeeding influence risk of type 2 diabetes in later life? A quantitative analysis of published evidence. Owen CG, Martin RM, Whincup PH, Smith GD, Cook DG. PMID: 17093156

...DESIGN: A systematic review of published studies identified 1010 reports; 23 examined the relation between infant feeding and type 2 diabetes in later life or risk factors for diabetes...RESULTS: Subjects who were breastfed had a lower risk of type 2 diabetes in later life than did those who were formula fed (7 studies; 76 744 subjects; odds ratio: 0.61; 95% CI: 0.44, 0.85; P = 0.003). Children and adults without diabetes who had been breastfed had marginally lower fasting insulin concentrations than did those who were formula fed (6 studies; 4800 subjects; percentage difference: -3%; 95% CI: -8%, 1%; P = 0.13); no significant difference in fasting glucose concentrations was observed...CONCLUSION: Breastfeeding in infancy is associated with a reduced risk of type 2 diabetes, with marginally lower insulin concentrations in later life, and with lower blood glucose and serum insulin concentrations in infancy.

Lower Rates of Breastfeeding in Women with Diabetes

Diabet Med. 2013 Sep;30(9):1094-101. doi: 10.1111/dme.12238. Epub 2013 Jun 21. Breastfeeding in women with diabetes: lower rates despite greater rewards. A population-based study. Finkelstein SA, Keely E, Feig DS, Tu X, Yasseen AS 3rd, Walker M. PMID: 23692476

...METHODS: A retrospective cohort analysis was conducted using data from four Ontario hospitals. Women who delivered a viable infant between 1 April 2008 and 31 March 2010 were included in the study...CONCLUSIONS: Women with insulin-treated diabetes had the poorest outcomes with respect to breastfeeding rates. Gestational and non-insulin-treated diabetes were associated with lower rates of breastfeeding in hospital, while gestational diabetes was additionally associated with lower breastfeeding rates on discharge.

Dtsch Med Wochenschr. 2008 Feb;133(5):180-4. doi: 10.1055/s-2008-1017493. [Breastfeeding in women with gestational diabetes]. Hummel S, Hummel M, Knopff A, Bonifacio E, Ziegler AG. PMID: 18213549

...METHODS: Breastfeeding habits (breastfeeding of any duration) were recorded of 257 mothers with gestational diabetes...who participated in a prospective post-partum study between 1989 and 1999 and compared to breastfeeding habits of 527 healthy mothers... all enrolled in the prospective BABYDIAB study between the years 1989 and 2000...RESULTS: Compared to children of healthy mothers, fewer children of mothers with gestational diabetes were breastfed (75% vs 86%; P<0.0001). Among breastfed children the duration of full or any breastfeeding was shorter in children of mothers with gestational diabetes (median for full breastfeeding 9 weeks. [mothers with gestational diabetes] vs. 17 weeks. [healthy mothers]; p<0.0001; median duration of any breastfeeding 16 weeks. vs. 26 weeks.; p<0.0001)...Full and any breastfeeding was shorter in women with insulin-dependent gestational diabetes than in those with diet-controlled gestational diabetes (full breast-feeding 4 weeks. vs. 12 weeks.; p<0.01 and any breastfeeding 10 weeks. vs. 20 weeks,; p<0.0001)....

Bonehead Ideas: High Cholesterol Equals High Cesarean Rates in Obese Women

Periodically, the obstetric world comes up with some bizarre theories as to why "obese" women have higher cesarean rates than women of average size.

The reasons behind higher rates is a valid question, but the way in which the obstetric world examines the question reveals much of their biases and assumptions around obesity.

One of their more persistent theories is the "Fat Vagina" theory, where they theorize that the vaginas of high-BMI women are lined with fat pads that will prevent a baby from getting out. Sadly, many doctors and midwives are still taught this theory as if it is established fact, when in truth, there is no data to back it up.

And of course, the current favorite among many providers is the "High Prenatal Weight Gain" theory, where women who gain more than the approved amount of weight are blamed for cesareans. And since any gain at all in obese women is considered "too much" by many providers, this may play a particularly potent role in the cesarean rate in women of size. But providers making a causal connection between high gains and cesareans completely ignore the role that fear and bias around high gains can play in many labors. It may not be high gains per se that cause more cesareans but rather the fears and interventions common in high-gain women (especially "high" gain obese women) that result in more cesareans.

One of the more ludicrous theories that doctors have come up with in recent years to excuse abysmally-high cesarean rates in fat women is the "Cholesterol Inhibits Myometrial Activity" theory.

Sadly, this theory gained a lot of mention in obstetric literature in recent years, despite very limited and dubious evidence to support it.

High Cholesterol Causes Cesareans?

In the Cholesterol Theory, high cesarean rates in fat women are supposedly caused by high cholesterol rates (since, you know, all fat women have high cholesterol) because high cholesterol rates supposedly impair the contractility of the uterine muscle.

Say what? Yeah, I know, that was my reaction too.

But yes, it was an actual theory put forward by a number of researchers in recent years. (And its kissin' cousins, that leptin or some other substance are the guilty parties instead.)

Because, you know, all fat women are defective and this explains how.

So the theory goes, if we give fat pregnant women statin medications, maybe that will cut their cesarean rate. Yes, there are actually doctors who have proposed doing this.

Fortunately, there is a recent study out that casts serious doubt on this bonehead Cholesterol Theory.

Problems with the Cholesterol Theory

I've written about this issue before, pointing out that the Cholesterol Theory has a number of problems.

First of all, many fat women do NOT have high cholesterol at all. (I'm one of them.) Many fat women have perfectly normal cholesterol levels, particularly during childbearing years. The fact that researchers assume that nearly all fat people have high cholesterol is symbolic of the typical assumptions researchers make about fat people and how these impact their ability to reach sound conclusions.

Second, the studies on "poor contractility" in obese women are quite small. This certainly raises the question of how whether the findings could be related to coincidence or confounding factors, rather than showing a true causal relationship. But virtually no one raises this question. They are happy to just jump to conclusions.

Third, please note that many of the studies supposedly showing "poor contractility" in obese women were done on women having planned cesareans with NO labor. How does this prove how they might have labored in real life? They took samples of the uteri before labor even started, and then did some lab tests on them, testing "contractility" in the lab.

Sorry, this is hardly indicative of real-life labor and birth, and since they did pre-emptive cesareans on these women, how can they prove that these in vitro "contractility" tests really have any relationship to how labor would have gone? There is just no way that this proves that there is something wrong with fat women's uteri.

Furthermore, they did not look for any other explanations for lower contractility in vitro. Studies show that fat women tend to have longer menstrual cycles and longer pregnancies. Planned cesareans like these were often done at 38 or 39 weeks, and if obese women tend to go into spontaneous labor closer to 42 weeks (either due to inaccurate dating from longer cycles or because of a tendency towards longer pregnancies), doing such an early cesarean would not reliably show whether their uteri were inherently "less contractile." Rather, it would simply suggest that these obese women were not even close to spontaneous labor yet and therefore less responsive to stimulants.

The bottom line is that these studies have a lot of issues.

While it's not wrong to propose a hypothesis for an observed problem, you have to be careful about jumping to conclusions too quickly. These studies relied on very small sample sizes, speculated about an obese woman's response to labor based on in vitro testing from a pre-labor cesarean, didn't explore alternate causes for the findings, and generalized assumptions about obesity and cholesterol levels in a very broad and questionable manner.

The Cholesterol Theory is FAR from a proven connection, although you'd never know it, based on the way many researchers discuss it. And the research certainly does not support routinely putting fat women on statin medications.

The Newest Study on Cholesterol and Cesareans

My biggest question last time I wrote about this issue was whether they had done any studies to see if the fat women who delivered vaginally had better cholesterol levels than the ones who had cesareans, or whether thin women with high cholesterol had more cesareans.

Well, finally we have a study directly addressing some of this. A recent study from New Zealand compared delivery method (cesarean vs. vaginal birth) with women's cholesterol levels at 14-16 weeks to see if there was a correlation between high cholesterol and cesareans.

They found there was NO correlation between the mother's cholesterol levels in early pregnancy and her delivery method. 

However, surprise surprise, they found that induction of labor was connected to cesareans. Imagine!

They concluded:

Elevated maternal cholesterol in early pregnancy is not a risk factor for first stage caesarean for failure to progress in overweight/obese women. 

Conclusion

This "High Cholesterol Causes Cesareans in Obese Women" theory is the kind of bad science that makes fat people so distrustful of medicine and doctors.

So often, it's all just based on ASSUMPTIONS about fat people and not on any real detailed study or logical questioning of theories.

Furthermore, the fact that several years ago they publicized this theory without having proven it and were even marketing the idea of giving statins was absolutely irresponsible.

Statins are CONTRAINDICATED in pregnancy; they are category "X" and may cause birth defects. Cholesterol and lipids play a very important role in fetal development. There is a reason why a pregnant woman's cholesterol rises during pregnancy; the baby needs it for development. Artificially lowering these levels may have devastating effects on the baby.

Critics responded that they were "only" suggesting putting fat women on statins in the last few months of pregnancy, so therefore there would be no risk of birth defects. But if these drugs can be so dangerous in early pregnancy, who knows what kind of harm they might cause late in pregnancy as well? There are other harms that can be caused to babies besides birth defects during organogenesis.

No one knows for sure what critical roles cholesterol and lipids play during late pregnancy. Pregnant women's cholesterol levels rise through pregnancy, suggesting that it has an important biological role to play in the end of pregnancy. Putting women on statins at the end of pregnancy may be just as harmful as at the beginning of pregnancy, just perhaps with more subtle problems than birth defects.

What it boils down to is that they were proposing using fat women's babies as lab rats to experiment on, based on extremely flimsy theories. This is UNACCEPTABLE.

There is completely insufficient evidence to support the idea that high cholesterol is the cause of the high cesarean rate in fat women, and the safety of statins in pregnancy at ANY stage is highly questionable. To suggest treatment with statins for anyone during any stage of pregnancy is risky and BAD science.

Furthermore, to be running stories in the media suggesting statin use in fat pregnant women before suitable research was done substantiating the Cholesterol Theory was reprehensible. It smacks of a few researchers looking for a "hook" to gain name recognition and funding (or a drug company looking for new revenue streams), rather than serious and responsible scientists pursuing a legitimate investigation.

You can read more about the original story here.

It is time for researchers to stop jumping to conclusions about fat women and pregnancy, time for them to examine their own faulty assumptions about obesity and how this distorts their research, time for them to stop using fat women's babies as lab rats for their own personal theories, and time for researchers to stop prematurely "spinning" preliminary research in order to get name recognition and research funding.

It's far too easy for care providers to blame the high cesarean rate in obese women on Fat Vaginas, High Cholesterol, High Prenatal Weight Gain or whatever other boogeyman is currently popular in the obstetric literature. This blames the victim and conveniently absolves themselves of blame.

It is long past time for obstetric researchers to stop blaming women and do the uncomfortable job of examining how their own practices and biases raise the cesarean rate in obese women.


References

BMC Pregnancy Childbirth. 2013 Jul 9;13:143. doi: 10.1186/1471-2393-13-143. Elevated maternal lipids in early pregnancy are not associated with risk of intrapartum caesarean in overweight and obese nulliparous women. Fyfe EM, Rivers KS, Thompson JM, Thiyagarajan KP, Groom KM, Dekker GA, McCowan LM; SCOPE consortium. PMID: 23835080 Full text available here.

BACKGROUND: Maternal overweight and obesity are associated with slower labour progress and increased caesarean delivery for failure to progress. Obesity is also associated with hyperlipidaemia and cholesterol inhibits myometrial contractility in vitro. Our aim was, among overweight and obese nulliparous women, to investigate 1. the role of early pregnancy serum cholesterol and 2. clinical risk factors associated with first stage caesarean for failure to progress at term. METHODS: Secondary data analysis from a prospective cohort of overweight/obese New Zealand and Australian nullipara recruited to the SCOPE study. Women who laboured at term and delivered vaginally (n=840) or required first stage caesarean for failure to progress (n=196) were included. Maternal characteristics and serum cholesterol at 14-16 weeks' of gestation were compared according to delivery mode in univariable and multivariable analyses (adjusted for BMI, maternal age and height, obstetric care type, induction of labour and gestation at delivery ≥41 weeks). RESULTS: Total cholesterol at 14-16 weeks was not higher among women requiring first stage caesarean for failure to progress compared to those with vaginal delivery (5.55 ± 0.92 versus 5.67 ± 0.85 mmol/L, p= 0.10 respectively). Antenatal risk factors for first stage caesarean for failure to progress in overweight and obese women were BMI (adjusted odds ratio [aOR (95% CI)] 1.15 (1.07-1.22) per 5 unit increase, maternal age 1.37 (1.17-1.61) per 5 year increase, height 1.09 (1.06-1.12) per 1cm reduction), induction of labour 1.94 (1.38-2.73) and prolonged pregnancy ≥41 weeks 1.64 (1.14-2.35). CONCLUSIONS: Elevated maternal cholesterol in early pregnancy is not a risk factor for first stage caesarean for failure to progress in overweight/obese women. Other clinically relevant risk factors identified are: increasing maternal BMI, increasing maternal age, induction of labour and prolonged pregnancy ≥41 weeks' of gestation.

Theories on Cholesterol, Leptin, and Myometrial Contractility

Med Hypotheses. 2011 May;76(5):755-60. doi: 10.1016/j.mehy.2011.02.018. Epub 2011 Mar 5. Proposed biological linkages between obesity, stress, and inefficient uterine contractility during labor in humans. Lowe NK, Corwin EJ. PMID: 21382668

Cesarean delivery has reached epidemic proportions in contemporary western healthcare. For otherwise healthy first-time (nulliparous) women at term gestation with a single fetus in a head down position, the most common clinical diagnosis prompting cesarean delivery is dystocia, including clinical terms such as uterine dysfunction, failure to progress, arrest of dilation and/or arrest of descent of the fetal head. In 2006, the cesarean rate for this lowest risk population of childbearing women was 26% in the United States despite the goal of Healthy People 2010 to reduce this rate to 15% from a baseline of 18% in 1998. While multiple lines of evidence suggest that the nulliparous uterus is particularly vulnerable to a diagnosis of uterine dysfunction during labor, pathophysiologic explanations for this dysfunction have not been well described. The acute stress response has been implicated as one factor in this dysfunction for many years, while more recently the growing epidemic of adiposity among women of childbearing age has been suggested as an additional pathway by which myometrial cell function may be disrupted. Using both clinical and in vitro evidence, we hypothesize a combined model in which pathways of acute stress and changes associated with maternal adiposity, particularly exaggerated levels of cholesterol and leptin, may independently and synergistically impair the contractile apparatus of the myocyte leading to the clinical diagnosis of uterine dystocia and subsequent cesarean delivery.

Am J Obstet Gynecol. 2006 Aug;195(2):504-9. Epub 2006 May 2. Inhibitory effect of leptin on human uterine contractility in vitro. Moynihan AT, Hehir MP, Glavey SV, Smith TJ, Morrison JJ. PMID: 16647683

OBJECTIVE: The purpose of this study was to investigate the effects of leptin on human uterine contractility in vitro. STUDY DESIGN: Biopsies of human myometrium were obtained at elective cesarean section (n = 18). Dissected myometrial strips suspended under isometric conditions, undergoing spontaneous and oxytocin-induced contractions, were exposed to cumulative additions of leptin in the concentration range of 1 nmol/L to 1 micromol/L. Control strips were run simultaneously...RESULTS: Leptin exerted a potent and cumulative inhibitory effect on spontaneous and oxytocin-induced contractions compared to control strips...There was an apparent reduction in both frequency and amplitude of contractions. CONCLUSION: This physiologic inhibitory effect of leptin on uterine contractility may play a role in the dysfunctional labor process associated with maternal obesity, and the resultant high cesarean section rates.

Reprod Sci. 2007 Jul;14(5):456-66. Contractility and calcium signaling of human myometrium are profoundly affected by cholesterol manipulation: implications for labor? Jie Zhang, Kendrick A, Quenby S, Wray S. PMID: 17913965

The authors elucidate cholesterol's effect on human uterine contractility and calcium signaling to test the hypotheses that elevation of cholesterol decreases uterine activity and that oxytocin cannot augment contraction when cholesterol is elevated...Elevated cholesterol is deleterious to contractility and Ca2+ signaling in human myometrium. Cholesterol may contribute to uterine quiescence but could cause difficulties in labor in obese/dyslipidemic women, consistent with their increased cesarean delivery rates.

Obesity and Contractility

BJOG. 2007 Mar;114(3):343-8. Epub 2007 Jan 22. Poor uterine contractility in obese women.
Zhang J, Bricker L, Wray S, Quenby S. PMID: 17261121

OBJECTIVE: The aim of the study was to elucidate the reason for the high rate of caesarean section in obese women. We examined the following hypotheses: (1) obese women have a high incidence of complications related to poor uterine contractility--caesarean section for dysfunctional labour and postpartum haemorrhage. 2) The myometrium from obese women has less ability to contract in vitro. DESIGN: First, a clinical retrospective analysis of data from 3913 completed singleton pregnancies was performed. Secondly, in a prospective study the force, frequency and intracellular [Ca(2+)] flux of spontaneously contracting myometrium were related to the maternal body mass index. SETTING: Liverpool Women's Hospital and University of Liverpool. POPULATION: The clinical study involved all women who delivered in one hospital in 2002. The in vitro study myometrial biopsies were obtained from 73 women who had elective caesarean section at term. RESULTS: Maternal obesity carried significant risk of caesarean section in labour that was highest for delay in the first stage of labour (OR 3.54). The increased risk of caesarean section in obese women largely occurred in women with normal- and not with high-birthweight infants. Obese women delivering vaginally had increased risk of prolonged first stage of labour and excessive blood loss. Myometrium from obese women contracted with less force and frequency and had less [Ca(2+)] flux than that from normal-weight women. CONCLUSIONS: We suggest that these findings indicate that obesity may impair the ability of the uterus to contract in labour.

Midwives Can Safely Care for Obese Women

Image Credit: Andy Ellison

In many places, midwives are no longer permitted to care for obese women, or at least obese women over a certain BMI (often 35 or 40). 

Many women of size these days are "risked out" of midwifery care, homebirth, birth centers, waterbirth, and even some hospitals. Some OBs are even refusing to see obese patients at all. A fat woman's only choice for care may become a high-risk specialist, even if she is healthy and has no complications.

I've written about this before. I call it Ghettoizing Women of Size.

It is done based on hyperbole around the risks of obesity and does not reflect the fact that many obese women are healthy, do not develop complications, and do just fine with midwifery or other "alternative" care. 

In the following recent Dutch study, although more obese women had their care transferred to OBs (some of which could simply represent bias or exceeding BMI cutoffs rather than actual complications), the obese women who were cared for by midwives had no more adverse outcomes than other women.

This shows that, providing there are no major complications, obese women (and even "morbidly obese" women) can be safely cared for by midwives.

There is no need for automatic transference of care, and definitely no need for routinely ghettoizing obese women into high-risk, high-intervention care.

*Midwives, let's see some more formal studies of midwifery care of obese women. Personally, I'd love to see a study comparing outcomes of healthy obese women routinely assigned to OB care and those routinely assigned to midwifery care. 

Reference

BJOG. 2014 Mar 12. doi: 10.1111/1471-0528.12684. [Epub ahead of print] The impact of obesity on outcomes of midwife-led pregnancy and childbirth in a primary care population: a prospective cohort study. Daemers D1, Wijnen H, van Limbeek E, Budé L, Nieuwenhuijze M, Spaanderman M, de Vries R. PMID: 24618305

OBJECTIVE: To assess the impact of obesity on the likelihood of remaining in midwife-led care throughout pregnancy and childbirth. DESIGN: Secondary analysis of data from a prospective cohort study. SETTING: Dutch midwife-led practices. POPULATION: A cohort of 1369 women eligible for midwife-led care after their first antenatal visit. METHODS: First-trimester body mass index (BMI) was calculated as weight measured at booking divided by height squared. Obstetric data were retrieved from medical records. Multiple logistic regressions were performed to examine the effects of BMI classification on midwife-led pregnancies and childbirths. MAIN OUTCOME MEASURES: Percentages of women remaining in midwife-led care throughout pregnancy and throughout childbirth. RESULTS: Of women in obesity classes II and III, 55% remained in midwife-led care throughout pregnancy and 30% remained in midwife-led care throughout birth. Compared with women of normal weight, women in obesity classes II and III had fewer midwife-led pregnancies (OR 0.38, 95% CI 0.21-0.69), and women who were overweight or in obesity class I had fewer midwife-led childbirths (OR 0.63, 95% CI 0.44-0.90; OR 0.49, 95% CI 0.29-0.84, respectively). Compared with women of normal weight, women who were obese had higher referral rates for hypertensive disorders (4 versus 14%), prolonged labour (4.6 versus 10.4%), and intrapartum pain relief (4 versus 10.4%). The women who were eligible for midwife-led birth and who were overweight or obese, had no more urgent referrals than women of normal weight. Women who were obese and who completed a midwife-led birth had no more adverse outcomes than women of normal weight, with the exception of higher rates of large for gestational age (LGA) babies (>97.7 centile; 12.1%, versus 1.9% in normal weight and versus 3.3% in overweight women). CONCLUSIONS: Although fewer women who were obese remain in midwife-led care during pregnancy and childbirth, there was no increased risk of unfavourable birth outcomes for women who were obese and eligible for a midwife-led birth when compared with women of normal weight. This indicates that when primary care midwives use a risk assessment tool throughout pregnancy and childbirth they are able to safely assign women who are obese to either midwife-led or obstetrician-led care.

Prenatal Vitamins, Pre-Eclampsia, and Obesity

Image from Wikimedia Commons

Here is the abstract for a recent study that found that use of a prenatal vitamin in the first trimester of pregnancy substantially reduced the risk for development of pre-eclampsia, especially in "overweight" and "obese" women. 

The most intriguing finding of the study was that taking a prenatal vitamin in the first trimester lowered the risk for pre-eclampsia by 55% in "overweight" women, and by 62% in "obese" women. 

Surprisingly, only about 1/3 of women of any size in this study actually took a prenatal vitamin during the first trimester. Other studies of relatively affluent first-world countries show that only about 30-60% of women routinely took prenatal vitamins before or in the first trimester. This is why improving prenatal vitamin use is a public health intervention which could have significant potential impact. 

This may be especially true in obese women, since women of size tend to have lower rates of prenatal or preconception supplement use (45% vs. 60% in one study). 

The $64,000 question is whether we can lower pregnancy complication rates in obese women by encouraging them to routinely take prenatal vitamins, even when not actively trying to get pregnant.

Caveats to the Study

The findings of this study are intriguing and deserve to be followed up. However, keep in mind that this is a relatively small study and that these results need to be duplicated multiple times before a true correlation can be established.

Also keep in mind that other studies on prenatal vitamin use (multiple or single vitamins) in the overall population have found more ambivalent results or even poorer outcomes with routine supplementation. 

So it's important not to over-interpret this one study or make broad policy recommendations based on it.

Still, it was significant that prenatal vitamin use made such a difference in women of size in this study. Why might this be?

Research suggests that many women of size have nutrient deficiencies such as low vitamin D, and some research suggests that low levels of vitamin D or other nutrients may be associated with higher risk for pre-eclampsia, so this could be explain why prenatal vitamin use was so helpful. However, not all research supports such an association, so again, caution is needed. 

It might be that supplementation is most beneficial only for those with significant nutrient deficits. A more sensible policy might be routine pre-conception nutrient testing for those most at risk rather than routine supplementation across the board for everyone. 

Since obese women are at significant risk for pre-eclampsia and certain birth defects, pre-conception nutrient testing is something that women of size who are considering pregnancy might want to consider. 

Personally, I favor pre-conception testing and emphasizing the use of whole foods and excellent nutrition as the best approach to lowering the risk for complications in women of size. 

To me, the best approach is always to emphasize nutrition before pills. I think artificial pills only go so far in helping nutrient deficiencies, and vitamin supplements of one or two particular vitamins can sometimes induce imbalances of other vitamins or minerals. Frankly, focusing on increasing dietary intake of fruits and vegetables may be the safest way to improve nutritional status and decrease risks before and during pregnancy.

Still, there is a place for vitamins and/or medications at times. A prenatal vitamin before pregnancy and during the first trimester might be helpful for many people. It seems like a common-sense public health strategy that might help and is at minimal risk for harm if it's done in moderation.

But the bottom line is that we need more studies showing the effect of routine prenatal vitamin use in subgroups such as overweight and obese women. I would particularly like to see research stratified by class of obesity, nutritional intake, pre-conception nutrient status, and insulin resistance status so we could have a more nuanced examination of potential confounders as well. 

Only when such nuanced research is done will we truly know for sure whether routine pre-conception and prenatal vitamin supplementation is an effective strategy for lowering the risk of complications in women of size. 

Reference

Matern Child Nutr. 2014 May 22. doi: 10.1111/mcn.12133. [Epub ahead of print] First trimester multivitamin/mineral use is associated with reduced risk of pre-eclampsia among overweight and obese women. Vanderlelie J1, Scott R, Shibl R, Lewkowicz J, Perkins A, Scuffham PA. PMID: 24847942

The use of pregnancy-specific multivitamin supplements is widely recommended to support maternal homeostasis during pregnancy. Our objective was to investigate whether multivitamin use during pregnancy is associated with a reduced risk of pre-eclampsia. 

The effect of multivitamin use on incidence of pre-eclampsia in lean and overweight/obese women was analysed using data collected between 2006 and 2011 as part of the Environments for Healthy Living Project, Griffith University, Australia. A total of 2261 pregnancies were included in the analysis with pre-eclampsia reported in 1.95% of subjects. 

Body mass index (BMI) ≥ 25 was associated with a 1.97-fold [95% confidence interval (CI): 0.93, 4.16] increase in pre-eclampsia risk. First trimester multivitamin use was reported by 31.8% of women and after adjustment, was associated with a 67% reduction in pre-eclampsia risk (95%CI: 0.14, 0.75). 

Stratification by BMI demonstrated a 55% reduction in pre-eclampsia risk (95%CI: 0.30, 0.86) in overweight (BMI: 25-29.9) and 62% risk reduction (95%CI: 0.16, 0.92) in obese (BMI: ≥30) cohorts that supplemented with multivitamins in the first trimester of pregnancy. This finding may be particular to the Australian population and reflect inherent nutritional deficits. 

First trimester folate supplementation was found to reduce pre-eclampsia incidence [adjusted odds ratios (AOR) 0.42 95%CI: 0.13, 0.98] and demonstrated significance upon stratification by overweight status for women with BMI >25 (AOR 0.55 95%CI: 0.31, 0.96). These results support the hypothesis that multivitamin supplementation may be beneficial in reducing the incidence of pre-eclampsia during pregnancy and be of particular importance for those with a BMI ≥25.

Famous Fat Folk: Sophie Tucker, Last of the Red-Hot Mamas

One of my favorite Vaudeville performers was Sophie Tucker (1884–1966).

She was known as the "Last of the Red-Hot Mamas."

She combined an earthy sense of humor with a big rounded body and never let others keep her down.

Life

Sophie was born to a Jewish family in Russia as they were emigrating to the United States. They settled in Connecticut when she was just a baby. 

Her original name was Sophia [or Sonia] Kalish, but the family changed its last name to Abuza when it emigrated.  Later, during a brief marriage at age 19, she took her husband's last name, "Tuck," which she later adapted to Tucker for her stage name.

She worked in her family's restaurant business as she grew up, often singing for tips. According to the website, Jewish Women's Archive, she recounted:

I would stand up in the narrow space by the door and sing with all the drama I could put into it. At the end of the last chorus, between me and the onions there wasn't a dry eye in the place.

Sophie and her son, Bert

She was married 3 times in her life but none of her marriages lasted for long. She had a son, Bert (see picture to left), with her first husband.

After they divorced, she left Bert with her parents while she went to New York City to make a career and often sent home money from her earnings to help support them.

She married twice more but each experience was unhappy and left her determined to be independent and happy on her own:

Sophie Tucker married and divorced twice more before giving up on marriage, proclaiming, in song, "There isn't going to be a fourth Mr. Ex/ And I'll be damned if I'm paying any more alimony checks/ I'm living alone and I like it."

She felt that philanthropy was very important and supported many charities. She died at age 82, from lung and kidney ailments.

Career

Sophie Tucker had a long and varied career.

She started in vaudeville with a comic shtick routine, and this vaudeville material influenced her style for the rest of her life.

She was briefly in the Ziegfeld Follies, but was so popular that many of the other performers refused to go on with her because she upstaged them.

In time, she branched out to (rather forgettable) movies, then developed a nightclub act in which she revisited her vaudeville material while also developing more sentimental songs.

In her later years, she was a frequent guest on music and variety shows on TV like The Ed Sullivan Show. 

She toured incessantly and performed right up until a few weeks before her death.

Weight

Although actually not that large, Sophie was always considered a big girl in the entertainment world. Even as a young teenager, she was often called "the fat girl." Her early managers were afraid she was "too fat and ugly" to make it on stage.

Rather than let it work against her, she used it as part of her act, and was often self-deprecating about it. As one source comments:

Tucker's stage image emphasized her "fat girl" image but also a humorous suggestiveness. She sang songs like "I Don't Want to Be Thin," "Nobody Loves a Fat Girl, But Oh How a Fat Girl Can Love."

Late in her career she sang a song called, "I'm the 3-D Mama with the Big Wide Screen."

In her most famous song she sang, "You're gonna miss your big fat momma some of these days."

She took a perceived negative and turned it into a positive by playing the underdog and making her audiences root for her. The fact that the "fat and ugly girl" became most famous for her racy, sexy material was an irony not lost on her.

Bawdy Overtones


A lot of Tucker's stage personality was based on a bold, brassy, sexy persona, singing songs of humorous raciness.

This earned her the billing, "The Last of the Red Hot Mamas" but her material was just ambivalent enough that it could be interpreted innocently or not-so-innocently, which kept her away from the worst censorship of the time. 

Some of her racy songs included, "I May Be Getting Older Every Day (But Younger Every Night)," "When They Start to Ration My Passion, It's Gonna Be Tough on Me," "Making Wicky-Wacky in Waikiki," and "You've Got to Make It Legal, Mr. Siegel."

Singing "The Angle-Worm Wiggle" got her removed from the stage in 1910 but the judge threw out the case.

Performing Style

As her act progressed, Tucker hired Ted Shapiro as her accompanist. He became a long-time part of her act, exchanging witty banter with her in between numbers. He also wrote some of her songs.

She usually used a narrative, half-speaking style in her songs, especially as she aged, but could sing when needed.

Her voice was not very good, but her comic style and brassy delivery influenced later entertainers like Mae West, Ethel Merman, and Bette Midler (who has a stage character named "Soph" and who supposedly named her daughter after Tucker).

Tucker was fiercely independent after all her failed marriages, and that was often reflected in her repertoire. Some of her songs included "A Good Man Is Hard to Find," "You Can't Deep-Freeze a Red-Hot Mama," "Too Much Lovin'," "Never Let the Same Dog Bite You Twice," "I'm Living Alone and I Like It," "I Ain't Takin' Orders from No One," and "No Man is Ever Gonna Worry Me."

Her songs about independence from men made her popular with women, but men liked her for her bawdy humor. She toured vaudeville houses and music halls through the United States and Europe, taking on a more nostalgic style as the years progressed and vaudeville went out of vogue.

Although she could be quite flamboyant, dressing in furs, jewels, feather boas, and outrageous wigs and hats, she also could effectively deliver serious or highly sentimental songs, earning her the title of "The First Lady of Show Business" by the end of her career.

Controversies

As with many other performers of that era, her early career is deeply entwined with racist practices common to the time, like singing in blackface and doing covers of African-American songs.

In 1907, when Tucker got her first break in vaudeville, they insisted that she perform in blackface. However, one day when her costume trunks got lost, she had to go onstage without it and became more popular without it, thereafter dropping the practice.

She hired African-American composers to write songs for her and sang in a style influenced by ragtime and blues. She hired vaudeville and blues greats Mamie Smith and Ethel Waters to give her singing lessons in those styles. In 1910, African-American composer Shelton Brooks wrote "Some of These Days." Tucker purchased exclusive rights to sing it and it became the signature song of her act and the title of her 1945 autobiography.

Tucker also made a name for herself by singing for Jewish audiences. She sang songs like "My Yiddishe Momme" by Jack Yellen and Lew Pollack, a highly sentimental song about a mother's sacrifice, which she began singing after the death of her own mother. She explained:

Even though I loved the song and it was a sensational hit every time I sang it, I was always careful to use it only when I knew the majority of the house would understand Yiddish. However, you didn't have to be a Jew to be moved by 'My Yiddish Momme.' 'Mother' in any language means the same thing.

In addition to performing, Tucker was active in efforts to unionize professional actors, and was elected president of the American Federation of Actors in 1938. This did not endear her to show business executives but her efforts to gain better conditions made her popular with performers and those working behind the scenes. In one story, the Teamsters were on strike when she died, but the hearse drivers put down their signs temporarily for her funeral procession to honor her memory.

Devotion to Charity

Tucker was a believer in doing good works. According to the Jewish Women's Archive:

Tucker was known for her reverence of the Hebrew principle of tzedaka, charity and acts of good will toward others. In 1945, she established the Sophie Tucker Foundation, donating time, energy, and resources to an ecumenical assortment of causes. Tucker contributed to the Jewish Theatrical Guild, of which she was a life member, the Negro Actors Guild, and the Catholic Actors Guild, as well as the Will Rogers Memorial Hospital, the Motion Picture Relief Fund, synagogues, and hospitals. She supported Israel Bonds, and her foundation endowed a Sophie Tucker chair at Brandeis University in 1955.

In 1959, on the first of several trips to Israel, Tucker dedicated the Sophie Tucker Youth Center at Beit Shemesh in the Judean Hills. Two years later, she sponsored another youth center at Kibbutz Be'eri in the northern Negev near Gaza. In 1962, she sponsored the Sophie Tucker Forest near the Beit Shemesh amphitheater and raised money for another forest. She also donated time and money to numerous hospitals and homes for the aged.

Tucker used her economic independence to empower herself and others, which created tensions in her personal life. Early in her career, Tucker had helped many of the prostitutes who lived in the same rooming houses as she, stashing money from their pimps, noting that, "Every one of them supported a family back home, or a child somewhere." While on tour, she brought her band to play in houses of prostitution for women who'd taken the night off in her honor.

Tucker felt that it was her economic independence that doomed her marriages to Tuck, accompanist Frank Westphal, and manager Al Lackey, all of which ended in divorce. As she explained it: "Once you start carrying your own suitcase, paying your own bills, running your own show, you've done something to yourself that makes you one of those women men like to call 'a pal' and 'a good sport,' the kind of woman they tell their troubles to. But you've cut yourself off from the orchids and the diamond bracelets, except those you buy yourself."

Stories and Quotes

Here are some of Sophie Tucker's most famous quotes:

• "I've been rich and I've been poor. Believe me, honey, rich is better."  [Whether she or someone else actually said this is disputed, but it's generally attributed to her.]
• "I couldn't make [her mother] understand that it wasn't a career that I was after. It was just that I wanted a life that didn't mean spending most of it at the cookstove and the kitchen sink."
• "Gradually, at the concerts, I began to hear calls for 'the fat girl'.... Then I would jump up for the piano stool, forgetting about my size, 145 pounds at age 13, and work to get all the laughs I could get."
• “I was never sylph-like. I was always big and husky.”
• From Raymond Stanley's Show Buzz: Kenn Brodziak, who engaged her, had never met her before but, immediately she alighted from the plane and he had introduced himself, she took him aside and clutched his arm. Very gently she said: “Don’t let the TV cameras near me - it’ll hurt your box office!”
• "From birth to age eighteen, a girl needs good parents. From eighteen to thirty-five, she needs good looks. From thirty-five to fifty-five, she needs a good personality. From fifty-five on, she needs good cash." 
• "I would start off with a lively rag, then would come a ballad, followed by a comedy song and a novelty number, and finally, the hot song. In this way, I left the stage with the audience laughing their heads off."
• "I've never sung a single song in my whole life on purpose to shock anyone. My 'hot numbers' are all, if you will notice, written about something that is real in the lives of millions of people."
• "Laugh and the whole world laughs with you. Weep and you sleep alone."
• "Success in show business depends on your ability to make and keep friends." 

Bette Midler incorporated some of Sophie Tucker's more bawdy humor into her stage show, or used it as inspiration for her own naughty comic riffs in Soph's personality. You can read more about these here. [Keep in mind, these are definitely not for the easily offended.]

Videos of Performances

Here is a recording of Sophie performing "Red Hot Mama."

  References

*Archive Recordings of Sophie Tucker:

• https://archive.org/details/SophieTucker-51-60
• https://www.youtube.com/watch?v=lJoYosDemHQ - My Yiddishe Momme
• http://www.rhapsody.com/artist/sophie-tucker/album/the-very-best-of - The Best of Sophie Tucker, a song collection

**Material drawn from several sources, including:

• Wikipedia's entry on Sophie Tucker
• http://sophietucker.com/
• http://jwa.org/discover/infocus/comedy/tucker.html - Jewish Women's Archive. "JWA - Jewish Women in Comedy - Sophie Tucker" (May 22, 2010)
• http://bootsalesounds.blogspot.com/2007/09/sophie-tucker.html
• http://everything2.com/title/Last+of+the+Red+Hot+Mamas
• http://womenshistory.about.com/library/bio/blbio_tucker_sophie.htm
• http://www.qotd.org/quotes/Sophie.Tucker
• http://blogs.smh.com.au/executive-style/allmenareliars/2011/06/02/sophietucker.html