Tuesday, January 26, 2016

pre-pregnancy caffeine intake may affect miscarriage risk

 

Most of us think nothing of downing a couple of cups of coffee a day. After all, just last year a U.S. government panel declared that coffee could be part of a “healthy lifestyle” and that most Americans could consume up to five cups without ill effects.
This advice, of course, comes with many caveats. Most people know that those with high blood pressure, diabetes or other health conditions may want to be more conservative in their caffeine intake. But a new study raises questions about a different subgroup: couples seeking to have a baby.
A study conducted by the National Institutes of Health and Ohio State University and published this month in the journal Fertility and Sterility has found a worrisome link between caffeine consumption and miscarriage.
[Brain-zapping gadgets promise to make you a better you — smarter, stronger, even happier]
The analysis involved information from the Longitudinal Investigation of Fertility and the Environment Study, which includes 501 couples interested in having children who were recruited to participate between 2005 to 2009. The men and women were asked to record their daily use of cigarettes, caffeinated drinks, alcohol and multivitamins during pre-conception and early pregnancy. They were asked to use ovulation detection and digital pregnancy kits to track the pregnancies. A pregnancy test’s conversion from a positive to negative, onset of menstruation or clinical confirmation were all categorized as pregnancy losses.
The data shows that couples who drank more than two caffeinated drinks a day during the weeks before conception had a higher risk that the woman would miscarry. That’s right — the study found that both Mom’s caffeine intake and Dad’s caffeine intake could play a role.
“Our findings also indicate that the male partner matters, too,” said Germaine Buck Louis, who directs population health research at NIH’s Eunice Kennedy Shriver National Institute of Child Health and Human Development. In fact, Buck Louis said, a man’s pre-conception consumption of caffeinated beverages was just as strongly associated with pregnancy loss as a woman’s.
Theories about how a man’s caffeine consumption affects a woman’s pregnancy mostly involve the sperm. Previous research conflicts on how caffeine affects sperm. But one of the larger studies, published in 2010 in the American Journal of Epidemiology and based on a sample of 2,554 young Danish men, found that high cola intake of more than 14 half-liter bottles a week and/or high caffeine intake of more than 800 milligrams a day were associated with both a reduced sperm concentration and total sperm count. (A typical eight-ounce cup of coffee contains about 100 milligrams of caffeine.)
The NIH study also confirms previous research that shows that women who drink more than two caffeinated beverages each day during early pregnancy — defined in this study as the first seven weeks — may also be more likely to miscarry. In the study, 98 of the 344 women with a singleton pregnancy lost a baby.
The authors of the NIH study cautioned that they don’t know for sure whether it’s the caffeine that caused the pregnancy loss and noted that those women who drank a lot of caffeine during pre-conception and lost their babies also tended to be on the older side, age 35 or older. That could mean that the health of the fetus may have been affected by the advanced age of the sperm and egg in older couples or by environmental exposures that could become cumulative over time as people age.
Finally, there was one piece of positive and practical news in the study: Women who took a daily multivitamin before and after conception appeared to greatly reduce miscarriage risk.

Researchers from Hasselt University in Belgium report a strong association between a mother's body mass index before pregnancy and the predicted lifespan of their child. A higher pre-pregnancy body mass index correlates with shorter telomere length - an indicator of a shorter overall life expectancy.
[Newborn baby contemplating]
Children born to mothers with a high BMI before pregnancy may be at risk of having a shorter lifespan.
Telomeres are an essential part of human cells that affect how cells age. Just as the plastic tips at the end of shoelaces prevent the laces fraying so that they can continue to do their job effectively, telomeres are the caps at the end of each strand of DNA that prevent DNA strands becoming damaged.
Cells replenish by copying themselves, and this process continuously occurs throughout a lifetime. Every time a cell copies itself, while the DNA remains intact, telomeres become shorter. Longer telomeres allow cells to divide more often. Ultimately, over a lifetime, telomeres become too short to work, which causes cells to age and stop functioning properly.
Telomeres shorten with age. However, telomeres can also become shortened through stress, smoking, lack of exercise, and poor diet. Telomere shortening is involved in all aspects of the aging process on a cellular level; short telomeres are linked to premature cellular aging. Telomere length represents an individual's biological age as opposed to chronological age.
A relationship has previously been found between telomere length in adults and age-related diseases, such as cardiovascular disease, type 2 diabetes, and increased mortality. Now, in a new study - published in BMC Medicine - researchers have conducted telomere research in newborns.

Assessing how maternal BMI affects telomere length

The team hypothesized that overweight or obesity during pregnancy could be a major factor in the telomere length of the child at birth and may, as a result, contribute to the developmental programming of the child.
The aim of the study was to evaluate the possible effects of maternal obesity in newborns on telomere length measured in the newborn's cord blood DNA and placental DNA.
"Compared with newborns of mothers with a normal BMI [body mass index], newborns of women with obesity are older on a molecular level, because shortened telomere lengths mean that their cells have shorter lifespans," says Prof. Tim Nawrot, the corresponding author. "So maintaining a healthy BMI during a woman's reproductive age may promote molecular longevity in the offspring."
Telomere lengths were measured in 743 samples of cord blood and 702 samples of placental tissue from newborns of mothers involved in the ENVIRONAGE birth cohort study in Belgium. The 743 women included in the research were between the ages of 17-44, and the average pre-pregnancy BMI was 24.1.

Each one-point rise in maternal BMI shortens offspring's life by 1-2 years

Previous research has indicated that people usually lose around 32.2-45.5 telomere base pairs per year during adulthood. This study showed that for every one-point increase in the mothers' BMI, telomeres in the newborns were around 50 base pairs shorter.
The 50 base pair shortening of telomere length in newborns is equivalent to the length people typically lose in 1.1-1.6 years of adult life, which may put children with shorter telomeres at a greater risk of chronic diseases in adulthood, such as heart disease and type 2 diabetes.
Co-author Dries Martens notes that the team ruled out various other factors that may potentially be associated with telomere length, including parents' age, socioeconomic class, ethnicity, mothers' smoking status, newborns' gender, and birth weight.
"Prior to our study, there was no evidence of an association between pre-pregnancy BMI and newborn telomere length, although meta-analyses suggest an association between BMI and telomere length in adults," says Prof. Nawrot.
"Our results add to the growing body of evidence that high maternal BMI impacts fetal programming, which could lead to altered fetal development and later life diseases. The public health impact of our findings is considerable as in affluent societies about 30 percent of women of reproductive age are overweight."
Prof. Tim Nawrot
Limitations of the study may include lack of data on paternal BMI. Previous studies have reported heritable changes in gene expression linked to the weight of a father on their newborn.
Read about how using antidepressants in pregnancy is linked to speech and language disorders in children.
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When Elinor Sullivan was a postdoctoral fellow at Oregon Health & Science University in Portland, she set out to explore the influence of food and exercise habits on obesity. In one experiment, she and her colleagues fed a troop of macaque monkeys regular chow. Other macaques dined American-style, with a hefty 32 percent of calories from fat and ready access to peanut butter treats. Over time, the second group of monkeys grew noticeably fatter.
Then they all had babies.
Sullivan, now at the University of Portland, noticed odd behavior in the plump moms’ offspring. At playtime, they often slinked off by themselves. When handled by keepers, the infants tended to vocalize anxiously, and the males became aggressive. They were prone to repetitive habits, like pacing.
In their carefully controlled world, the only difference between those monkeys and others at the facility was their mothers’ extra pounds and indulgent diet. The behavior was so striking that Sullivan changed the course of her research.“It made me start thinking about human children,” she says, and the twin epidemics of obesity and behavioral problems such as attention-deficit/hyperactivity disorder. Her research, published in 2010 in the Journal of Neuroscience, was one of the first studies to note that the progeny of female monkeys eating a high-fat diet were more likely to experience altered brain development and suffer anxiety. Not long after, researchers worldwide began compiling evidence linking the heaviness of human mothers to mental health in their children. One headline-grabbing study of more than 1,000 births, reported in 2012, found that autism spectrum disorders showed up more often in children of obese mothers than in normal-weight women (SN: 5/19/12, p. 16).
Over the course of a generation, obesity rates among U.S. women have soared. Today, 38 percent of females in the population are obese (defined as a body mass index of 30 or higher). Among women of childbearing age, well over half are overweight or obese, with almost 8 percent considered extremely obese (a BMI of 40 or greater). Lucilla Poston, who is head of the division of women’s health at King’s College London, calls too much weight during pregnancy “the biggest problem in obstetrics at the moment.”
Within the body, obesity is not a passive state. Excess weight can inflame the immune system, upset the balance of hormones and even alter the microbial flora tucked inside the intestine. If shared by the fetus, any or all of these changes can affect the baby’s development in subtle but important ways. Further complicating matters, the fetus is probably being exposed to the effects of fattening, and perhaps inflammatory, foods.
Only recently have researchers begun to understand what this physiological storm might mean for children. In part, obesity during pregnancy raises the odds that a baby will be born overly large, setting the stage for future health problems (SN: 5/31/14, p. 22). But when a mother is excessively overweight, risks persist even for newborns of normal size. One study published in 2013 in the journal BMJ analyzed medical records of more than 37,000 people born in Scotland between 1950 and 1976. After accounting for socioeconomic status, gender, weight at birth and many other variables, the researchers found that children born to obese mothers had a 35 percent higher mortality rate from birth to 2012. “Independent of birth weight, a child can grow up with increased blood pressure, obesity and risk of diabetes,” Poston says.
The list doesn’t stop there. Perhaps most surprisingly, a mom’s metabolic state might compromise her child’s mental health—the very observation that changed Elinor Sullivan’s career. One study published in 2015 even raises the possibility that a child’s normal cognitive development might be slightly impaired by mom's high BMI.
If there is a bright spot, it’s that unlike many threats during development, this one is preventable. As the risks of obesity during pregnancy emerge, researchers hope more young women on the verge of starting families see the importance of maintaining a healthy life—and that the culture around them will support efforts to do so. “Pregnancy is a good time to talk to people about lifestyle,” Poston says, “because they do care deeply about their babies.”

Womb with a clue

Few research questions are easy, but epidemiologists studying maternal obesity face a particularly daunting challenge. They have to separate the effects of a mother’s weight from a multitude of other influences on children’s health. In the United States, obesity disproportionately affects low income and minority women. Children born in less affluent neighborhoods face obstacles to their well-being: more stress, heightened exposure to pollutants and less access to wholesome foods. Plus, the same food choices and lack of activity that drive a woman’s weight gain may also become the lifestyle adopted by her children.
The data become even more difficult to tease apart when examining effects on the mind. Given the correlation of obesity with poverty, children of obese parents also might have educational disadvantages. Case in point: Studies have found that young children in poverty score lower on measures of school readiness, including motor-skill development, emotional health and social knowledge.
That said, the latest studies—many published in recent months—attempt to overcome those biases. And they still find reason for concern. Lisa Bodnar, a nutritional epidemiologist at the University of Pittsburgh, describes a “small but growing literature” suggesting that obesity in a mother is associated with lower cognition and other mental health challenges in children. In 2015 in the Journal of Nutrition, Bodnar and her colleagues published a study of women on similar economic footing who were patients at Pittsburgh's Magee Women’s Hospital. The majority were unemployed, single mothers. The researchers nonetheless found that children of women who were obese at conception or gained excess weight during pregnancy scored slightly lower on tests of intelligence and executive function, a measure of the ability to plan, organize and adjust to new situations.
Probably the most compelling data link maternal obesity with ADHD, says Sullivan, who continues her primate studies. Whether maternal obesity (or a fattening diet) can actually cause hyperactivity is unclear, but one study of rodents published in Molecular Psychiatry in 2012 described results that “point to a direct biological link between in utero exposure to maternal obesity and hyperactivity in the adult offspring.” Researchers from England and Sweden fed one group of female mice a high-fat diet that started six months before pregnancy and lasted until weaning, while another group ate regularly. The offspring of the obese mothers scored significantly higher on tests of hyperactivity.
Another animal study, published in 2014 in the Journal of Neuroinflammation, found that female offspring of mice fed a high-fat diet had increased anxiety while the males were prone to hyperactivity. The study, from the Mayo Clinic in Rochester, Minn., and Oregon Health & Science University, also opened the door to prevention. When mother rats were given a healthier, less inflammatory diet while nursing, the mental health of the female pups improved, though the males still had issues.
In November 2015, Sullivan and colleagues reviewed the evidence in Hormones and Behavior, making the grim prediction that, given persistent rates of obesity and pervasiveness of high-calorie foods, “the prevalence of neurodevelopmental and mental health disorders will continue to rise in future generations.” In December, researchers from George Washington University and Mathematica Policy Research announced that 12 percent of U.S. children and adolescents have been diagnosed with ADHD, a 43 percent increase since 2003.
The field is still too new to explain biologically how obesity would impair fetal brain development, but Sullivan points to theoretical consequences of high glucose or the hormone leptin. Leptin inhibits appetite, but is often elevated in obese individuals and may affect brain development. Most commonly, however, researchers circle back to the effects of an agitated immune system on the brain. “We think of obesity as the state of chronic inflammation,” Sullivan says. “Many of the neurotransmitters in the brain are very sensitive [to inflammation] in early development.”

Baby buggy

The immune system isn’t the only part of body mechanics co-opted by obesity and diet. A compelling line of inquiry has linked the microbiome—specifically the microorganisms inside the digestive system— to body weight. For example, the microbiome of an obese person differs from the microbiome of someone of normal weight. In experiments involving lean mice with no intestinal microbes, transferring the microbiome of an obese person to a thin mouse is enough by itself to make the lean mouse pack on weight.
Since a newborn gets its microbiome from mom, a baby could inherit microbes that want to hoard calories. In both human and animal studies, the microbiomes of offspring born to obese moms are different than in children born to lean moms, says Deborah Sloboda, a fetal physiologist at McMaster University in Hamilton, Ontario. “What we don’t know is whether it comes from transfer during pregnancy, transfer during birth or poor developmental environment altering how the gut forms.”
The intestine is normally a fortress that does not like micro­organisms to escape. Several studies, however, have suggested that when under siege from a fast-food Western diet, the gut lining can become porous (SN: 5/30/15, p. 18). Perhaps bacteria slipping into the bloodstream during pregnancy could affect proper formation of the intestine. Other scenarios are also possible: The microbiome transferred during birth could, as it has in animal experiments, predispose a child to a microbiome that extracts more calories from a given amount of food.
In Pediatric Research in 2015, Sloboda and colleagues reviewed research on obesity and the maternal microbiome. One theory holds, they noted,that the microbiomes of lean women remain stable during pregnancy; the microbiomes of obese women appear more volatile, experiencing a greater bloom of species associated with obesity. These women’s children may then start life with a microbiome inclined toward weight gain.
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Provoking problems

Like researchers who study the brain, Sloboda and others suspect that inflammation—which also appears to be a consequence of the microbiome coping with junk food—lies at the heart of many risks conveyed to a developing fetus. “When you consider the spectrum of conditions that have been linked to maternal obesity,” says immunologist Ilhem Messaoudi of the University of California, Riverside, “one of the things that links all these diseases is inflammation.”
In addition to the irritation that might come from the high-fat, high-sodium, high-calorie fare at the drive-through, adipose tissue itself provokes a mother’s immune system. In this state of overactivation, the normal cues for her baby’s immune formation might then become lost.
“If you have to develop an immune system in the presence of inflammation, the programming of the immune system is going to change,” Messaoudi says. In an experiment published in 2015 in Pediatric Allergy and Immunology, she and her colleagues studied 39 pregnant women who were designated as lean, overweight or obese, based on their preconception body mass index, a measurement of body fat. The researchers extracted blood samples from the umbilical cords of the women’s newborns, and tested the reaction to antigens, molecules that are supposed to trigger an immune reaction.
“The cord blood cells of babies born to obese moms did not respond to bacterial antigens,” she says. It was as if the immune system, put to its first real test, was stumped. “If your immune cells don’t know how to react, you’re going to be sick more often. You may not respond to vaccinations in the way your immune system is supposed to respond.”
Those findings may partially explain studies finding that children of obese mothers are more likely to develop disorders that arise from off-kilter immunity. In 2014, researchers who reviewed a dozen studies concluded in the journal Pediatrics that babies born to mothers with a high body mass index had a 20 to 30 percent greater risk of asthma and wheezing, though they noted that mechanisms remain unknown.

Rewired appetite

Of all the possible consequences of maternal obesity, the data are most compelling in suggesting that overweight mothers tend to raise children who grow up to be overweight themselves. “It’s a very strong effect, and consistent, across all populations,” says Bodnar, from Pittsburgh. Chinese researchers writing in 2013 in PLOS ONE pooled the analysis of 45 studies examining whether children faced greater odds of being heavy based on mom’s size. Although studies have varied and genetics obviously play some role, the scientists concluded that having an obese mother roughly tripled the risk of obesity.
In addition to a woman’s weight when she becomes pregnant, excessive weight gain during pregnancy, especially in the first months, is also linked to her child’s obesity risk. In one 2012 study comparing more than 6,600 Finnish mothers, those who put on more pounds during the first 20 weeks of gestation (compared with those who gained the least) had children who were 46 percent more likely to be overweight at age 16.
Theories to explain the association are examining how increased glucose and hormonal balance affect fetal development, particularly in the brain. Leptin resistance, which leads to higher secretion of the hormone, can be a consequence of obesity. In the journal Acta Physiologica in 2014, Poston and her colleagues from King’s College pointed out that many studies have found that the presence of too much leptin can cause collateral damage to the developing hypothalamus, a key interface between the brain and the hormone-producing endocrine system.
Animal studies suggest an altered hypothalamus could mean a child is born with difficulty regulating blood pressure and controlling appetite. “That particular part of the brain may become rewired, and a child may grow up eating more,” Poston says.
With little sign that the obesity epidemic is abating, that theory and others are likely to take on increasing importance in medical research. This generation’s greatest health threat could leave an unexpected legacy. Scientists working in this field often worry that their research will be seen as solely finding fault with mothers. “I think it’s unfair to blame this on women,” Bodnar says. Obesity is a global problem. One starting point, she says, is for more doctors to speak with their patients about the importance of weight. Since half of all pregnancies are unplanned, those conversations should happen before a woman gets pregnant. Yet in a U.S. study published in 2014, overweight women of child-bearing age received diet and exercise advice during preventive medicine exams only 36 percent of the time. The number was even lower among pregnant women who were overweight.
At the same time, Bodnar says, this is not going to be fixed in doctors’ offices. Women every day are offered cheap, calorie-dense food, pushed by companies with fat marketing budgets (McDonald’s alone spends about $900 million a year on advertising). “It’s not easy, in this environment, to lose weight,” Bodnar says. “We have to agree as a society that this matters.”
This article appears in the January 23, 2016, issue of Science News under the headline, "Maternal Input: A mother's weight during pregnancy can shape her child's mental and physical health."

You may not be pregnant yet, but there’s plenty you can do now to make yourself as healthy as possible for a growing baby. Consider this your preconception to-do list:
  1. Make an appointment with your doctor. It’s true: You’ll be seeing her plenty after you conceive. But it’s a good idea to book a visit ahead of time, too, even if you’ve been pregnant before. If you have any health issues that could affect your chances of conceiving or that could make a pregnancy more risky, it’s important to get those under control now. If diseases like cystic fibrosis or sickle cell disease run in your or your partner’s family, you might also want to see a genetic counselor or do preconception screening tests.
  2. Check your gums. Good oral health is strongly linked to a healthy pregnancy. Gum disease is linked to early birth and low birth weight. See a dentist to tackle any problems.
  3. Quit smoking and drinking. You know tobacco and alcohol during pregnancy are never OK -- they’re bad for a baby’s growth and can cause health problems for him when he gets older. But even now, smoking and drinking can make it harder to get pregnant and raise your risk of a miscarriage. Talk to your doctor about programs that can help you quit these habits.
  4. Cut back on caffeine. Downing more than two cups of coffee or five cans of soda a day (that’s about 250 milligrams of caffeine) could make it harder for you to conceive and increase the chances that you’ll miscarry. Plus, switching to decaf now means you won’t have to put up with caffeine cravings during those first few weeks of pregnancy.
  5. Eat smart. There’s no better time to cut out junk food and all of its empty calories. Make sure you’re getting plenty of fruits, vegetables, whole grains, and lean protein every day. A healthy diet before you conceive can make you less likely to get gestational diabetes, a type that affects pregnant women.
  6. Shed extra pounds. Extra weight can raise your odds of problems like gestational diabetes and high blood pressure during pregnancy (your doctor might call this preeclampsia). It generally isn’t a good idea to lose weight while you’re pregnant, so start working on it now.
  7. Catch up on vaccines. Some illnesses during pregnancy could do more than make you miserable. They might hurt your child. Talk to your doctor about the vaccines you need now and which ones you’ll need later. Doctors give some shots (like the Tdap vaccine for whooping cough) during pregnancy so your baby can benefit from the protection, too.
  8. Think about the meds you take. It’s important to let your doctor know about all the drugs you’re taking -- prescription, over-the-counter, even vitamins and herbs. Some of them could affect your baby. Start taking a prenatal vitamin or folic acid supplement to lower your risk of birth defects.
  9. Get picky about seafood. You’ve probably heard that it’s smart to steer clear of fish that are high in mercury while you’re pregnant. But it can take up to a year for your body to clear the element from your blood. Fish on your plate twice a week is fine, but pass on the kinds that have a lot of mercury like swordfish, tilefish, king mackerel, and shark.
  10. Hit the gym. Not only will exercise help you get to a healthy weight, it’ll also get you into shape for labor and delivery. Once you’re expecting, look for special prenatal classes that are safe for moms-to-be.
 
You know how it goes: The moment the pregnancy test is positive, you give up alcohol, you cut out coffee, you try to make every bite count and limit your weight gain to healthy norms. You're suddenly responsible for two.
That's the usual strategy. But new data suggest that perhaps it’s time to rethink that logic — it could be, by the time you get that pregnancy test result, you're already late for the train.
Why? According to a recent study based on a sweeping analysis of more than 6 million births, there appears to be a robust link between a woman's weight even before she gets pregnant and her baby's risk of dying in her first year.
The numbers are small, but the researchers say they are significant:
Among normal-weight moms, about four in 1,000 babies die after birth; among moderately obese moms, that rises to nearly six babies per 1,000 and among morbidly obese moms, it's more than eight babies per 1,000 live births.
(To be precise, "normal weight" for a 5-foot-4 tall woman before she's pregnant is defined from 110-144 pounds; moderately obese is considered 175-204 pounds, and morbidly obese is 235 pounds or more.)
Obesity And Infant Deaths
Eugene Declercq, the study's lead author and a professor at the Boston University School of Public Health, puts it this way: If you are truly obese, with a Body Mass Index of 40 or above before pregnancy, your baby has a 70 percent higher mortality risk compared with a normal weight woman. (This holds true even after controlling for a wide array of risk factors in the study, including race, ethnicity, education, insurance coverage, diabetes and hypertension, he said.)
“Since this involves pre-pregnancy obesity it emphasizes the importance of thinking of women’s health in general and not just when they’re pregnant, which has too often been the case.”
Eugene Declercq
It's the persistent association between BMI and infant mortality that makes the research compelling, Declercq said: As BMI increases above normal, the infant death rate increases consistently too.
"This links up women's health and kids' health in a really important way," Declercq said in an interview. What it suggests, he adds, is that pre-pregnancy BMI still had a pretty strong relationship to both neonatal mortality (death in the first 28 days) and post-neonatal mortality (death in the first 28-365 days). "No matter how you cut it, that relationship is robust."
The researchers also wondered whether pre-pregnancy obesity was related to a specific cause of death: notably, prematurity, congenital abnormalities or SIDS. As it turned out, obesity was a problem in all of those categories.
"The really powerful finding would have been if all of the higher rates of infant mortality were explained by a single cause of death, but that wasn't the case here," Declercq said. "The implication, essentially, is it's not one thing we have to worry about — obesity is a multifaceted problem in terms of outcomes."
An 'Alarming' Rise In Obese Women
And clearly, the implications are broad. The American College of Obstetricians and Gynecologists recently reported an "alarming" increase in the number of obese women of reproductive age in the U.S.: More than half are overweight or obese.
"A major hope in initiating this project was to get the focus on women's health throughout her life course and not just when she's pregnant," Declercq said.
Lizzie, a 32-year-old chiropractor in Medford, Massachusetts, who asked that her last name not be used, says although she's not obese, she's definitely above her ideal weight.
Recently, Lizzie's ob-gyn told her that if she wants to get pregnant (which she does), losing 10 to 20 pounds would be a good idea. "Even though I knew it intellectually, it was very hard to hear," Lizzie said in an interview. "What bothered me the most was she said it but didn't give me anything else, she didn't talk about what I should do, no specifics about exercise or nutrition."
With a family history of diabetes and a sister who had gestational diabetes during pregnancy, Lizzie says she's trying to lose weight before conceiving, but it's not easy.
"I desperately don't want to repeat what my sister went through," she said. "But it's been a challenge ... I'm a big sugar person — that's my downfall, and a daily struggle."
A Fraught Discussion
Actually getting women to lose weight before they're pregnant is far easier said than done, says Dr. Naomi Stotland, a co-author of the recent Declercq study, and an ob-gyn at University of California San Francisco.
About half of pregnancies are unplanned, she says, which makes it hard to get the message across at the right time.
In addition, says Stotland, also on the faculty at San Francisco General Hospital, pressuring women to lose weight can be tricky for both doctors and patients. "Even if a physician is motivated to talk about it, the woman might not be in the right place to hear it." she said.
For example: If a patient has an appointment to get birth control, it may not feel appropriate for the gynecologist to say, 'Hey, maybe think about losing weight for that future, theoretical birth you're not planning to have any time soon,' she said. Also, doctors' own issues about weight complicate the matter: Thin doctors often feel awkward and non-compassionate urging patients to slim down, and overweight doctors feel they have little credibility, Stotland said.
A small 2010 study of pregnant overweight and obese women, called "What My Doctor Didn't Tell Me," concluded that women often don't feel their doctors are providing appropriate or helpful (or any) information on weight.
A Too-Accessible McDonald's
And the complications only increase when poverty is also in the mix, says Dr. Nidhi Lal, a primary care doctor at Boston Medical Center. She says in her practice, which includes hundreds of reproductive age women, with about 30 to 40 percent who are overweight or obese, access to healthy food is a major obstacle because many live in so-called "food deserts" where nutritious food is scarce and fast food and convenience stores proliferate.
"McDonald's and Dunkin' Donuts and 7-11's are more accessible and affordable than shopping at Stop and Shop or Market Basket," Lal said.
She said there are often deep misconceptions about food and pregnancy. For instance, some women assume that they need to start eating for two as soon as they start planning a pregnancy. "And these are women who are already overweight to begin with," she said.
And there are cultural issues too.
"Women who are raised in the U.S. want to be thin, but they don't always have the resources to get there and so they're reluctant to talk about body weight," Lal said. "They think I'm judging them or not being empathetic." Women from certain other cultures, she says, prefer being heavy: "It's a sign of attractiveness and prosperity."
For doctors, then, it's a tough path to navigate.
"It really requires a relationship of trust, a very non-judgmental kind of communication," Lal said. "I try to make my patients well informed, tell them as many facts as I can: 'This is why I want them to do this and how it can effect their pregnancy outcomes' — a mother will do anything for the her baby. I try not to be negative, and say, 'Oh no, you gained weight.' It takes a lot pre-visit planning."
Lal also tries to get her whole medical team involved, including consults with a nutritionist and prenatal nurse. Still, she adds: "It is hard to do everything in an empathetic manner in 15 to 20 minutes because despite what you say, they have their own sense of success and failure. Some are very discouraged because they are doing what they can but some things they can't control."
But the problem isn't going away. A slew of recent studies suggest that obesity before and during pregnancy can cause enduring health woes.
A study published in January found that children born to mothers with a combination of obesity and diabetes before and during pregnancy may have up to four times the risk of developing autism spectrum disorder compared to children of women without the two conditions.
And late last year, the American College of Obstetricians and Gynecologists, calling obesity the “the most common health care problem in women of reproductive age,” issued new recommendations on obesity and exercise during pregnancy. It cited a list of problems associated with obesity mainly during pregnancy, including a higher risk of miscarriage, premature birth, stillbirth, birth defects, cardiac problems, sleep apnea, gestational diabetes, preeclampsia and venous thromboembolism, or blood clotting in the veins.
'I'm Just A Fried Clams Girl'
But telling women to change their personal behavior in an across-the-board manner sometimes gets public health officials in trouble.
For example, there was a massive backlash against the Centers for Disease Control and Prevention when, earlier this year, it issued a blanket warning that sexually active woman of childbearing age and not using birth control should stop drinking alcohol — completely.
So, hitting the right tone when it comes to talking to women about their weight is key.
"Conveying the message is tricky since I wouldn’t want it to be another case of blaming mothers," Declercq, the researcher, said. "Since this involves pre-pregnancy obesity it emphasizes the importance of thinking of women’s health in general and not just when they’re pregnant, which has too often been the case."
Interestingly, his study, published online last month in the journal Obstetrics and Gynecology, also found that established recommendations from the Institute of Medicine on weight gain during pregnancy were largely not being followed. Those recommendations suggest that obese women limit weight gain to between 11 and 20 pounds during pregnancy, regardless of the severity of the obesity. However, there was essentially the same infant mortality risk among obese women who followed those guidelines compared to those who didn’t, the study found.
That finding raises several questions: Do the guidelines need rethinking? Or is there something about the genetics of obese women that persists through pregnancy even if some amount of weight is lost?
This study didn't address those issues, but one thing is clear for any future public health efforts: Women remain far more motivated if they think they're doing something for their babies, Declercq said. The trick is to get them to think about their own health as deeply as their kids' — and well in advance.
Take Amy, a mom from Arlington, Massachusetts, who gave birth to three children through IVF (and also asked for confidentiality). Between pregnancies, she says, it got harder to lose the weight. Now, while considering a fourth child, she says she should lose about 22 pounds.
Like many moms, Amy is vigilant about feeding her children healthy meals, but when it comes to her own diet: "I can't overcome my cravings for meatball subs...I don't really enjoy eating a salad." She said that while some people find pleasure in "racing cars or smoking" her downfall is high calorie foods. "You know what you're supposed to do, but actually doing it is the hardest part," she said. "If I have the choice between romaine lettuce and fried clams? I'm just a fried clams girl."
 
 
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