I spend a fair amount of time on parenting support boards. To receive, but also and mostly, to give support. I think parents in our generation, for the most part, don’t have access to the “village” that our parents and grandparents had for advice and support. The internet gives us a unique opportunity to connect and share information. It also, unfortunately, gives us a unique opportunity to judge, scrutinize, compare and generally make other people and/or ourselves feel like shit. That part needs to stop. I also spend a lot of time on fitness boards, particularly ones with other moms. I have noticed a disturbing trend: pregnant women feeling bad about their bodies.
This pregnant woman, generally speaking, has gained more weight than she expected, in places she didn’t expect and/or has been told by a medical provider, friend, mother, mother-in-law, article or online group that she needs to slow her weight gain. Because of this, she also is now desperate to continue her workouts or increase intensity and most importantly, not gain any more weight. But, yawn, unfortunately, yawn, she has a tiny human sucking the life directly out of her, swollen ankles, a baby head rubbing against her pelvic bone that feels as though it may drop out at any moment, or hyperemesis gravidum, like I did, and she can’t stop throwing up long enough to work out. And, that baby needs her to gain some weight, to help her grow and develop.
I, too, was VERY concerned about gestational weight gain (GWG). So, I asked both of my midwives (both certified nurse midwives, one with a Doctorate and one with a Master’s) about weight gain during pregnancy and was given roughly the same answer – you are healthy and at a healthy weight at the start of your pregnancy. Unless you or the baby develops a medical problem during the pregnancy, weight gain isn’t really something to be concerned about. This didn’t dissuade me from trying to limit my gain, however.
With my first pregnancy, I was underweight when I got pregnant and was committed to gaining the least amount of weight possible. I ate right and worked out diligently until the day I gave birth. I even ran a 24 minute 5K when I was 8 weeks along. After my second trimester, I mostly walked, lifted weights and did yoga. I gained about 40 lbs. I felt good and my provider was not concerned at all. She said that she saw women every day who gained twice as much as I had and still had healthy pregnancies, deliveries and babies. I also eventually lost most of my pregnancy weight, however, I was never as tiny as I was prior to growing a human. Which was probably a good thing.
With my second pregnancy, it turns out that my problem would be gaining. I couldn’t keep food down, so I lost about 10 lbs during my first trimester. We had to play with different combinations of drugs to enable me to keep anything down, and when I could, I ate high calorie foods to try to pack on lbs. I gained solace knowing my little vampire was likely getting what he needed. Eventually, I was able to eat and start gaining. I remember the appointment when I gained 5 oz. The nurse and midwife both gave me high fives. I was able to catch up and also gained about 40 lbs. with this pregnancy, too. Again, while this was higher than what is deemed “optimal,” neither my midwife, nor my maternal fetal specialist were concerned.
So why all of the pressure on pregnant women? The Institute of Medicine (IOM) released new gestational weight gain guidelines in 2009, that were expanded to include a recommendation for obese women, based on a review of evidence since their 1990 report. Much to my dismay, they are still based on BMI, which stinks as a measure of health or wellbeing and was never intended to be used as a measure of healthy weight. The report and its recommendations focuses on three things – getting pregnant at an optimal weight, gaining weight within an acceptable range based on your BMI prior to pregnancy and losing weight following delivery, to prepare you for your next pregnancies (like a good little vessel).
Interestingly, previous research and recommendations regarding GWG, were actually focused on ensuring that women gained enough weight and consumed adequate nutrition to avoid low birth weight for their babies, which is linked to poor health outcomes in infants, including infant mortality. Earlier recommendations of limiting weight gain and even dieting during pregnancy had been linked to those negative outcomes and they found that when doctors started encouraging women to gain more weight, fewer babies were born at a low birth weight. My own mom was advised to limit pregnancy weight gain in the late 70’s while pregnant with twins. Seems so backwards. So, why the shift away from gaining and nutrition and towards limiting weight gain? I think it’s a function of our culture. I mean, what’s worse than being fat? /sarcasm
Much to my surprise, in their official statement on the report, the American College of Obstetrics and Gynecology actually implies that these guidelines are too permissive for overweight and obese women, and that women should be supported in gaining less weight.
The IOM gestational weight gain guidelines provide clinicians with a basis for practice. Health care providers who care for pregnant women should determine a woman’s BMI at the initial prenatal visit (an online BMI calculator is available at http://www.nhlbisupport.com/bmi). It is important to discuss appropriate weight gain, diet, and exercise at the initial visit and periodically throughout the pregnancy. Individualized care and clinical judgment are necessary in the management of the overweight or obese woman who is gaining (or wishes to gain) less weight than recommended but has an appropriately growing fetus.
So what does the evidence tell us?
The purpose for establishing weight gain guidelines, as stated by the IOM is to prevent negative maternal outcomes.
There are numerous potential causal factors, including environmental factors, that can influence the determinants of GWG and its consequences and others that may affect those consequences by other routes. These consequences, i.e., adverse health outcomes to the mother, can arise in the prenatal and/or postpartum periods. Among the well-studied prenatal maternal outcomes that result from excessive GWG are pregnancy-associated hypertension (including preeclampsia and eclampsia) and risk of complications in labor and delivery. In the postpartum period, weight retention can lead to higher weight status in subsequent pregnancies as well as weight retention and other long-term maternal health consequences such as increased risk for type 2 diabetes and cardiovascular disease. Unfortunately the literature in this area does not allow inference of causality because it is based solely on observational studies.
However, it seems as though they are mixing up correlation with causation. When doing a close reading of their report, a common theme emerges – while research shows that obese women are more likely to have some negative maternal and birth outcomes – such as hypertension, insulin resistance and increased risk of cesarean section – the relationship between gestational weight gain and not simply whether or not the woman was overweight or obese prior to pregnancy and these conditions is not clear or studied enough to be conclusive. In fact, in the introduction to this report they actually tell us that they removed pre-eclampsia and gestational diabetes from their analysis, and essentially are most concerned about moms not losing their pregnancy weight and having to have cesarean sections.
The committee considered the incidences, long-term sequelae, and baseline risks of several potential outcomes associated with GWG…Postpartum weight retention, cesarean delivery, gestational diabetes mellitus (GDM), and pregnancy-induced hypertension or preeclampsia emerged from this process as being the most important maternal health outcomes. The committee removed preeclampsia from consideration because of the lack of sufficient evidence that GWG was a cause of preeclampsia and not just a reflection of the disease process. The committee also removed GDM from consideration because of the lack of sufficient evidence that GWG was a cause of this condition. Postpartum weight retention and, in particular, unscheduled primary cesarean delivery were retained for further consideration.
And like many government reports and public health efforts, they don’t take into consideration relevant individual factors – health status, muscle mass, activity level, body composition, diet, etc. and the end result is a set of recommendations for clinicians to use when working with women before they get pregnant, during pregnancy and after pregnancy to help them get and stay healthy, or in this case, to lose weight, not gain much and then lose weight again before their next pregnancy. Are you sensing a theme here?
But the problem with a one size fits all approach to the management of any health condition is that it is “one size fits all” when in fact, health is not “one size,” shape, etc. This is also problematic, because people who appear healthy (read: “are thin”), do not always get screened adequately for health conditions typically associated with obesity, like type 2 diabetes and heart disease. And while roughly 1/4 of people at a healthy weight have those and other metabolic conditions, roughly half of overweight and a third of obese people are perfectly healthy. And when a nation’s head doctors come up with guidelines that seem heavily focused on not wanting people to get fat, I think they are missing the mark.
In fact, the evidence that negative health outcomes are related to GWG is not strong enough for other country’s health programmes to provide similar guidance. In the UK, for instance, while the National Institute for Health and Care Excellence (aptly abbreviated NICE) recommends that women be weighed at their first appointment. They then recommend that women be given tailored advise and care:
At the earliest opportunity, for example, during a pregnant woman’s first visit to a health professional, discuss her eating habits and how physically active she is. Find out if she has any concerns about diet and the amount of physical activity she does and try to address them.
Advise that a healthy diet and being physically active will benefit both the woman and her unborn child during pregnancy and will also help her to achieve a healthy weight after giving birth. Advise her to seek information and advice on diet and activity from a reputable source.
Offer practical and tailored information.
Do not weigh women repeatedly during pregnancy as a matter of routine. Only weigh again if clinical management can be influenced or if nutrition is a concern.
This seems like a more balanced and woman-centered approach. And less likely to result in disordered eating amongst women before, during and after they grow humans.
My entirely non-medical opinion:
- Women who are growing humans should realize that this is the most badass thing imaginable and should cut themselves some slack – both during and following childbirth.
- Women who are growing humans should try to be healthy, eat well and get regular exercise. And if they can’t get regular exercise or can only keep down salt and vinegar potato chips or they gain more than their sisters-in-law, celebrity moms or Facebook friends, they shouldn’t sweat it.
- Women who are growing humans should find a health care provider they trust and can relate with so they can have frank and/or supportive conversations about what they can do to stay healthy during pregnancy.
- Women and their health care providers should focus more on health and nutrition and less on numbers. Care should be individualized and customized for each woman.
- Women should try not to compare themselves to others – in weight gain, postpartum weight loss, parenting or in general.
- If you see a woman post on a support board that she gained a lot of baby weight or is having trouble losing, don’t post about your 15 lb. gain and postpartum weight loss thanks to ItWorks!, tell her instead how badass she is for growing a human.
- Women, especially those who are growing humans, should be proud and amazed at what their bodies can do.
- Even if your body never looks the same, you never fit back into your pre-pregnancy jeans or you don’t lose all of your “baby weight” in the first few weeks after birth, it is okay. You don’t need excuses, you need acknowledgment. You fucking grew a human, badass!
Image credits: Steph, all rights reserved.