In case you haven't heard the story, apparently there's a group of OB/GYNs in Florida who are actively refusing to follow pregnant women who are obese.

The rationale they've presented is that they're too complicated, and for their patients' safety they're electing not to see them. Instead they're suggesting their patients with obesity get referred to specialized high risk obstetricians.

Now it's certainly a fair point to state that pregnancies in patients with obesity do carry more risk, both to moms and to babies, but the question that leaps to my mind is whether or not the OB/GYNs are telling the truth? Would the care they would be capable of providing these patients truly be substandard, or are they just avoiding taking on more complicated patients?

Put another way, are these OBs blatantly discriminating against people with obesity, or are they trying to protect them from their own professional inadequacies?

Now I'm not an OB, so for the sake of this discussion, I called up my friend Dr. Glenn Posner who's an OB here in Ottawa. Glenn broke it down practically. He confirmed that managing labor in women with obesity is more challenging. He told me that it's significantly more difficult to monitor the baby, and if things go sour, it takes more people to help in the OR and the skin-to-baby time for a crash C-section is much longer.

He also stated quite emphatically that just because there's a greater degree of difficulty didn't in his mind justify refusing to care for a significant, and growing, percentage of patients, and that indeed, any OB/GYN out there should be sufficiently trained to handle them.

Our discussion then turned to why these docs, who certainly are capable of caring for patients with obesity, have chosen not to.

We came up with a few options.

1. Overt and ugly bias.
2. Laziness - not wanting to have to deal with more complicated cases
3. Inadequate facilities - equipment does matter and depending on weight, may not be readily available.
4. Fear of litigation - with a much higher rate of complications, it may well stand to follow that there's a much higher risk of lawsuit.

Any way you slice it, it ain't pretty.

When I practiced more traditional family medicine and saw my pregnant patients many rationalized rapid and extreme weight gains as a rite of pregnancy and not a worry because after all, they were "eating for two".

It's probably time to rethink those attitudes.

Last week a paper was published in the Lancet which looked at a within family comparison of pregnancy weight gain and baby birth weight.

The study was rather enormous in scope capturing 513,501 women and their 1,164,750 children. The findings were pretty straightforward too - babies of women who gained more than 50lbs during their pregnancies were roughly 1/3lb heavier at birth than those of women who gained between 17-22lbs.

Moreover, compared to those gaining 17-22 pounds, the bigger gaining mothers were 1.7 times more likely to have a high-birth-weight baby, and those gaining more than 53 pounds were 2.3 times more likely to do so.

Doesn't sound like much, but there are some other things to keep in mind when considering the results.

Excessive pregnancy related weight gain is a very real driver of sustained maternal obesity, and bigger babies have been shown to be at greater risk of becoming obese adults.

Why do bigger babies have a greater likelihood of turning out to be obese adults? The working theory in the paper is that the intra-uterine environments of babies born to women with greater pregnancy weight gains are different and that these differences in turn impact on dietary behaviours over the child's lifetime.

Of course it's also possible that the dietary habits in homes of women who gain excessive weight during pregnancy differ from those who don't with these differences nurturing (rather than naturing) an impact on dietary behaviours over the child's lifetime.

Either way one thing's for certain - pregnancy is a wonderful opportunity to explore your diet and remember that the "two" you're eating for, ain't exactly an equal in size.

Eating for 1.2 sounds about right.

David S. Ludwig, & Janet Currie (2010). The association between pregnancy weight gain and birthweight: a within-family comparison The Lancet : 10.1016/S0140- 6736(10)60751-9

Last year the Institute of Medicine (IOM) revised their guidelines on weight gain in pregnancy.

The new recommendations state that obese women should gain between 11 and 20lbs during pregnancy (compared with a previous recommendation of 15lbs).

The Institute didn't stratify these recommendations to different classes of obesity and consequently whether you've got a BMI of 30 or a BMI of 45 the recommendations remain the same.

Many physicians (myself included) found this to be odd - both in terms of not stratifying recommendations for different obesity classifications and also for recommending any weight gain at all for women with moderate to severe obesity and this week a few like minded physicians took the IOM to task in an article published in the January issue of Obstetrics and Gynecology.

The issues of course are the risks for both mother and baby associated with maternal prenatal obesity. The authors suggest that weight gain during pregnancy and that gain's effect on subsequent weight gain in life (not losing post pregnancy),

"are causes of a permanent increase in weight for every BMI category and are significant contributors to the obesity epidemic and associated comorbidities"

They believe that the recommendations are skewed towards the theoretical health of the fetus only and fail to factor in weight gain's risks to the mother which include higher likelihoods of gestational diabetes, hypertension, operative deliveries, pre-eclampsia and neonatal complications which of course in turn put the fetus at risk.

The authors recommend that diet should be tailored for women of different classes of obesity resulting in gestational weight gains of 10lbs or less and in some, weight loss.

I couldn't agree more and while my sincere belief is that 1,500-2,000 calorie diets are sufficient to nourish a fetus and to effect in weight losses for pregnant women with class II and III obesity, thankfully there are studies underway to test that very hypothesis. Belief is a bad way to practice medicine.

Artal R, Lockwood CJ, & Brown HL (2010). Weight gain recommendations in pregnancy and the obesity epidemic. Obstetrics and gynecology, 115 (1), 152-5 PMID: 20027048

According to an article in Diabetes Care the number of pregnant women with pre-existing diabetes has doubled in just 6 years.

This was no small study either. The study looked at 175,249 women ages 13-58 years with 209,287 deliveries of 20 weeks gestation from 1999 through 2005.

Back in 1999 only 10% of children born to diabetic mothers were born to moms with pre-existing diabetes (90% were in moms who developed gestational, or during pregnancy, diabetes). By 2005, that number climbed to 21%.

Even more alarming?

The number of diabetic teenagers giving birth rose more than 5 fold.

Yup, diabetic teenagers.

We sure can't call it "adult-onset" any longer. Perhaps we should call it "nutritional" or "weight-related" diabetes?

On the newsfeeds today is a story about linking your future child's weight to the weight you might gain during pregnancy. What the study found was the children of women who gained more weight during pregnancy had a higher likelihood of being overweight at age 3.

The conclusions being drawn on the newsfeeds is that the issue of obesity in North America must therefore be due to weight gain during pregnancy. The fact is there are literally thousands of variables that affect weight and even more that affect eating behaviour.

Interestingly the only controls mentioned in the experiements were for race, parental smoking, household income and fetal growth during pregnancy. The only control I would want to know about is the eating habits of the household to begin with because guess what, children eat what parents buy and if the household has calorie dense choices, parental inactivity and poor nutritional education that's far more of a culprit in childhood obesity than anything else.

http://www.newscientist.com/channel/health/mg18825284.300

By far the best way to help your children is to live well yourself and let them learn from you.