Weight matters - addressing obesity in pregnancy and beyond.

This is a report of a meeting of the Forum on Maternity and the Newborn of the Royal Society of Medicine, held on Thursday 22nd November 2007.

Chairs: Mr Eugene Oteng-Ntim, President, Forum on the Maternity and the Newborn, and Dr Patricia Livsey, Head of the child development department, City University.

A shorter version of this report is published on line by the RCM Midwives Magazine.

Obesity in pregnancy - not neglect, but a problem.
T.G.Teoh (TGT), Obstetrician & Gynaecologist, St. Mary's Hospital, London

This presentation examines risk in relation to maternal body mass index (BMI) in a large unselected population; it is based on a retrospective analysis of data from a validated maternity database system in the North West Thames Region.

The BMI of women at booking is increasing, with the incidence skewed towards those of low income and the non-white races.

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A risk profile should be generated and from this an ideal weight gain for the pregnancy suggested. Every antenatal clinic should have a management strategy with individualised plans for obesity in pregnancy and for labour.

Effects of obesity on the mother.
The risk of PET doubles for each 5-7kg/m2 increase in BMI. The incidence of gestational diabetes mellitus (GDM) and its recognized adverse effects increase with the BMI. This is also apparent in women who gain 10lb between pregnancies, while the risk reduces for women who lose 10lb between pregnancies. The incidence of type two diabetes mellitus is on the increase prior to and during pregnancy. Urinary tract infections increase slightly with the BMI, but wound infections are significantly more frequent when the BMI rises above 30. The incidence of thromboembolic disease doubles in the obese pregnant.

The fetus is at risk from macrosomia, and the perinatal death rate increases. Raised blood glucose levels, not obesity alone, are associated with fetal malformations, but diagnosing these is inhibited by the difficulty of scanning the obese. Excessive BMI is associated with unexplained late fetal death in the pregnancies of nulliparous women. If by severe measures the weight gain in pregnancy is kept below 5 kgs. there is a useful reduction in the birth weight of the babies. Big babies are nine times more likely to become overweight adults.

The effects of obesity on pregnancy and labour.
The induction of labour rate for the obese is about 36% (25%), and the failed induction rate doubles. There is a doubling of operative delivery, shoulder dystocia, and severe perineal tears. The elective and emergency caesarean section (CS) rates can rise to almost 50%. Not only is the size of the babies a factor in the failure of labours to progress, but the uterine contractions have also been shown to weaken. Breastfeeding is liable to fail, perhaps because the prolactin response to suckling is reduced. The success rate of vaginal birth after CS (VBAC) declines.

Management.
The obese should be helped to lose weight before they become pregnant. During pregnancy we give them folic acid supplements, and check their glucose tolerance at 27 weeks. If scanning is required the transvaginal route is advisable. To prevent thromboembolism we advise graduated stockings, sometimes aspirin, and for BMI greater than 45, heparin injections throughout pregnancy. The women meet an anaesthetist prior to labour, and regional analgesia is preferred to general anaesthetic if required. Elective CS is unavoidable for the very obese (BMI over 40), in view of the impossibility of access for the treatment of shoulder dystocia or for vaginal examination and instrumentation. Care is taken to avoid post-operative haematoma in the subcutaneous fat.

Reference: Kanagalingam MG, Forouhi NG, Greer IA, Sattar N. 2005. Changes in booking body mass index over a decade: retrospective analysis from a Glasgow Maternity Hospital. BJOG 112: 1431-3.

Social inequalities in mother and child obesity.
Dr. Tim Lobstein (TL), Director, Childhood obesity programme, International Association for the study of obesity (Co-author)

There are socio-economic differences in the likelihood that a woman of reproductive age will be obese. An obese pregnant woman is at risk of significant complications in pregnancy and labour, and the infant is at risk of ill health.

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The social gradient of risk raises issues of what interventions are appropriate; health education alone is likely to be inadequate for lower income groups, and more active intervention is needed.

Statistically the majority of women in England are overweight or obese; the distribution is uneven, with a 30% incidence in Scotland and the Midlands, partly related to income levels and increasing age. Among the higher age groups in the childbearing era the incidence rises to almost 50%. There tends to be a cycle of obesity through the generations, as the babies with macrosomia become overweight children , adolescents and young women. There is least obesity in higher income groups (a tendency which starts in childhood); there is an environmental effect, since women with low incomes living in high income localities are less prone to overweight. Women with lower incomes get less antenatal education, and they have difficulty putting what they learn into practice; also they are prone to lower self esteem, leading to a careless attitude to diet and general poor motivation.

Add to these handicaps limited resources: a woman receiving benefit has about 13p to spend on food with 100 Calorie value - quite possible when the food is of poor nutritional quality. On a low income it is difficult if not impossible to afford the mix of foods recommended for the pregnant. Women classified as in Poverty3 - out of work for a long period and in debt - are struggling to afford a diet anywhere near adequate, as they are well aware. Benefit levels are much too low and should be reviewed; that portion of the benefit advised for healthy foods should be ring fenced, and increased to reflect the cost of sufficient required healthy food for at least 95% of those eligible. Our governments have refused to do this, and even to make recommendations as to how benefit should be spent on a healthy basket of foods. Benefit levels for women at the key age for reproduction, under 25 , single and pregnant, are particularly low. All organisations with the necessary influence should be campaigning for this to be corrected.

There are no official recommendations for the appropriate weight gain in pregnancy and its nutritional requirement; published by NICE these would be of great help for midwives, health visitors and doctors caring for the pregnant. Increased rates of breastfeeding will assist, but further interventions in the life course will be needed.

Food for thought: are maternity care professionals meeting the needs of obese pregnant women?
Sile O' Connor (SOC), Florence Nightingale School of Nursing & Midwifery, King's College, London (Co-author).

Post-industrial western society has witnessed the rise of a 'toxic food' culture, with the availability of high-calorie and high-fat food fuelling the current obesity crisis. The obesity rate in the U.K. is escalating rapidly, and the number of obese women of childbearing age is increasing. On the 7 March, 2007 The Telegraph proclaimed 'Extra Care for Fat Mothers; a burden on the NHS'. Maternal obesity has far ranging consequences for the health of both the mother and her baby. It is estimated that 22% of pregnant women will be obese by 2010 ( Heslehurst et al 2007 a), and in this context, and due to the media attention this has attracted, my presentation, based on a systematic literature review undertaken for my BSc Midwifery dissertation in July 2007 which examined the topic from feminist, historical, sociological and maternity perspectives, examines whether maternity care professionals are meeting the needs of obese pregnant women.

Body image for obese pregnant women is a complex topic, and we are left with an ambiguous impression of their feelings. In the literature it is argued that pregnancy can offer obese women the opportunity to feel more positive about their body image, as conventional western pressure that 'slim' equals 'beautiful' does not apply to pregnancy (Wiles 1994). Failure adequately to address maternal obesity was also underscored by the theme of communication. Obese pregnant women reported being offended and hurt by derogatory or insulting comments and unsolicited advice from professionals, who by implication were either unaware of or ignorant of the problem (Wiles 1994), and who reported feeling embarrassed about broaching the topic of weight (Heslehurst et al 2007b), revealing a chasm in communication.

The efficacy of weighing women in the antenatal period has been much debated (Ellison & Holliday 1997), leading to the policy to discontinue routine weighing antenatally. Confusion about women's appropriate weight gain during pregnancy permeates the literature (Wiles 1998; Heslehurst et al 2007b). Qualitative research studies of their experiences and feelings, and of the experiences and views of midwives on caring for them are required. The professionals must be made aware of the importance of broaching this sensitive topic with women. Embarrassment must be overcome as a part of holistic woman-centred care.

Local and national guidelines for obesity and weight gain in pregnancy are lacking, and multi-disciplinary care pathways with appropriate links to dieticians are needed (Krishnamoorthy et al 2006). One dietician stated that a referral service based on BMI would be useful (Heslehurst el al 2007b), particularly as women are more motivated to change lifestyle behaviours during pregnancy (Crafter 1997). A lack of resources means that the care requirements of obese pregnant women are not being met (Heslehurst el al 2007b).

I thank my dissertation supervisor Dr. Gillian Aston for her generous support throughout the gestation of my review paper.

References:

Crafter H. (1997) Personal and cultural influences on health. In: Crafter H (ed.), Health Promotion in Midwifery. Principles and Practice. London: Hodder, pp.22-33.

Ellison T.H. & Holliday M. (1997) The use of maternal weight measurements during antenatal care. A national survey of midwifery practice throughout the United Kingdom. Journal of Evaluation in Clinical Practice 3: 303-317.

Heslehurst N, Ells LJ, Simpson H, Batterham A, Wilkinson J, Summerbell CD. (2007a) Trends in maternal obesity incidence rates, demographic predictors, and health inequalities in 36821 women over a 15-year period. British Journal of Obstetrics and Gynaecology 114: 187 -194.

Heslehurst N, Lang, R, Rankin J, Wilkinson JR, Summerball CD. (2007b) Obesity in Pregnancy: a study of the impact of maternal obesity on NHS maternity services. British Journal of Obstetrics and Gynaecology 114: 334-342.

Krishamoorthy U. Schram CMH, Hill SR (2006) Maternal Obesity in Pregnancy: Is it time for meaningful research to inform preventive and management strategies? British Journal of Obstetrics and Gynaecology 113: 1134-40.

O'Connor S. (2007) ''Food for Thought': Are midwives meeting the needs of obese pregnant women?' Unpublished BSc Midwifery Dissertation, Florence Nightingale School of Nursing & Midwifery, King's College, London.

Wiles R. (1994) 'I'm not fat, I'm pregnant' in Wilkinson S, & Kitzinger C. (eds.) Women and Health: feminist Perspectives. London: Taylor & Francis: 33-49.

Wiles R. (1998) The views of women of above average weight about appropriate weight gain in pregnancy. Midwifery. 14: 254-260.

Can childhood obesity be fixed in the UK? Preventing and tackling child obesity: The MEND Programmes.
Mr Paul Sacher (PS), National Obesity Forum and Research Director for MEND (Mind, Exercise, Nutrition and Do it!) (Co-author)

The MEND Programme is the largest family and community-based multi-component intervention for childhood obesity in the UK, but during this presentation please bear in mind the frequency of excessive weight gain in pregnancy, and think about how this might be remedied using the methods I shall describe which are in use by MEND. Possibly we have something to offer. You are likely to find that an approach that is successful in one maternity unit is not been replicated anywhere else. Such a method needs to be cost-effective, something you can recommend to a NHS Trust; it must be sustainable, to ensure that initial progress in a mother's weight control is maintained throughout pregnancy. Perhaps groups could attend outside the hospital, in leisure centres or schools, working on healthy eating during pregnancy, breastfeeding and weaning.

The mission of MEND is to enable a significant, measurable and sustained reduction in childhood overweight and obesity levels; a third of children in the UK are affected. Thus the programme comprises behaviour change, physical activity, information on nutrition, and empowering and motivating people to make the changes for themselves, making that personal choice. Much of MEND's work is in developing effective interventions, in obesity awareness training and the training of leaders to run the various programmes.

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The programme has been developed over the last six years by leading child obesity experts in the UK. It and Mini_MEND, the programme for toddlers, are community and family-based, structured, evidence-based and replicable. MEND is underpinned by a multi-site randomised controlled trial (RCT), which was completed in early 2007. Results from the RCT show that the programme is effective in achieving statistically significant and sustained improvements in key health outcomes at 12 months such as BMI, waist circumference, increased participation in and uptake of physical activity, reduced sedentary behaviour, as well as substantial improvements in self-esteem. A second, larger-scale RCT is planned at the UCL Institute of Child Health.

Delivered by a wide range of trained health, education and exercise professionals in partnership with Primary Care Trusts, local authorities and leisure providers, the programme comprises twenty 2-hour early evening group sessions over ten weeks. Parents are taught how to reduce their children's nutritional intake, for example by differentiating hunger from craving. The whole family is shown how to interpret food labels, and there are sessions on cooking and fruit and vegetable tasting. Exercising is on land and in water if available, and measurements are taken at the start and end of each programme to evaluate health outcomes.

The approach used by MEND differs from other healthy lifestyle programmes in relying on a strong evidence base and a commitment to ongoing research and continuous improvement. It has been designed from the outset to be replicable and scalable, and it focuses on ongoing sustainability. Standardised resources include a full kit of all the teaching aids required to run the programme, as well as in-depth training; these are provided to local areas commissioning MEND, to ensure that the programme can be implemented quickly and easily with minimum lead-time, in a manner that ensures standardisation, quality assurance and cost-effectiveness. Furthermore, MEND provides robust monitoring and evaluation of outcomes for local programmes, as well as ongoing programme management support from central staff and a sophisticated online project management system. Sustainability is promoted through a suite of services for graduates of the programme, including quarterly newsletters, ongoing reunion events and motivational phone calls.

The data we collect from each parent and child include the BMI of both, the child's birth weight and gestational age, details of infant feeding and current eating behaviours, other behaviour patterns such as television watching, and the style of feeding employed by the parents. Feedback is important, and can be very satisfying:

feedback
I am particularly pleased with the 86% attendance rate; imagine the enthusiasm and perseverance required in a busy family to achieve this; the course was completed by 97% of the families. Representatives of the 260 centres which operate the programme attend conferences twice annually. Best practice is shared, and we have a system of awards; standardisation is ensured by the identical four-day training periods and the manuals, but we recognise that centres may make improvements, and these are rewarded. All the data collected is entered in a web-based programme, eventually to be derived from 26,000 families, resulting in the world's largest childhood obesity intervention database.

Our newer programme for two to four-year-olds and their parents, Mini-MEND, lasts 10 weeks with one weekly session; its target is primary prevention, inclusion being independent of weight. There are physical activities for the parents and children together, and customised crèche activities including story-telling to reinforce the messages. Each child is given a spoon and a cup; we hope that the spoon will be associated with Mini-MEND, and well help them to accept foods with new flavours. The cup is intended to get babies off dependence on feeding bottles. There is substantial attendance by single parent and ethnic families, and not seldom the cost of the food for their children was said to be prohibitive; we are identifying frequent and regrettable behaviours such as insistence on feeding by anxious parents, and eating in front of television; the hours of television viewing by these toddlers are well above recommended levels. Only one third had been breastfed for four to six months.

We have been unsuccessful in the getting funding from government, and so we hope that the commercial sector, responsible for so many of the problems, will be co-operative, leading to public/private partnerships. If we do nothing, half of the boys in primary schools will be obese by the year 2050 (Foresight Programme report October 2007).

Discussion.

Questioned about the role of food addiction PS emphasised introducing children to new flavours, eliminating sugar as far as possible, and using unrefined carbohydrates, which are effective in reducing appetite. Many of these children are eating something every twenty minutes; they experience wide variations in blood sugar, with resulting hyperactivity and hunger. Adjustments such as a change from white to whole-grain bread and the exclusion of fizzy drinks have good results in terms of behaviour and eating patterns.

PS: Lack of central funding is inhibiting the study of childhood obesity throughout the population.

An obstetrician deplored the discontinuation of weighing during pregnancy. "We would total up the gain in weight due to increased blood volume, the growth of the uterus, the placenta, amniotic fluid and baby, and any weight gain beyond this is excessive fat requiring to be lost after the pregnancy".

SOC: I have been pleased today to identify a more forgiving, supportive and less punitive attitude among the professionals. Eating for the relief of psychological pain must not be ignored. A delegate who runs an obesity support group recommended this method of mutual support. PS: MEND uses practical suggestions and encouragement rather than therapy, for which our members are not trained.

PS: At present we do not have data analysing the numbers of clients coming from the many sources of referral and by self referral; attendance rates may vary in significant ways. Work on motivation is obviously important.

PS: A MEND group requires three workers: an assistant, usually a volunteer , a theory leader and an exercise leader. Each works for two hours twice weekly. The all-in cost varies between £250 and £380 per family. This is far less than the cost of medication and particularly surgery. The Department of Health has calculated that a sustained reduction of one BMI Unit saves the NHS £7,500. MEND is seen to be cost effective, and it is generally agreed that multi-component, community based approaches are the way to go.

Professor Wendy Savage found in her work that a simple approach such as pointing out that it is unnecessary to eat for two, since the baby will take what it needs, can be effective in limiting excessive weight gain in pregnancy. PS believes that an oversimplified approach may leave women feeling that they are failures. A professional is more likely to take a sympathetic approach if he or she has experienced this complex problem. Working with families has to be the key to preventing childhood obesity becoming adult obesity. If we are to address the problem around pregnancy work should start before or at a particular stage in pregnancy; there seems to be uncertainty about this at present. 1