Monday, May 15, 2017

Manual Lymph Drainage and Bandaging --- Does It Work?

My feet, before and after Manual Lymph Drainage and wrapping
Images copyright Pamela Vireday, April 2017. Please ask permission before using. 
After many years of stage 2 and 3 lipedema, a serious health crisis recently propelled me into stage 4 lipo-lymphedema, where the body cannot dispose of its lymph fluids properly.

This led me to try some manual lymph drainage and bandaging to see if that could help the lipo-lymphedema.

It did. It wasn't a miracle cure but it did help, as you can see in the pictures.




The process starts out with a soft cotton stocking, then the leg gets wrapped in more padding..


Then the bandaging continues with special bandages until it's all covered.


You leave this on for a day to two days. This is the hard part. You want to take it off! It's restrictive but not too bad, fortunately. It's just hard to be patient.



Then you take it off for the final reveal. Here you can see how different in size the two feet are after treatment. Huge difference, if it it's not obvious in the pictures. I recently had the second foot done to help it reduce too.

Has it been worth the trouble of treatment? Yes, it has in my situation. I am much more comfortable now than before. Has the treatment maintained itself? Yes, to some degree. Some edema has returned but most has not and I'm still better off than I was before the treatment.

It's up to you whether or not to try this therapy, and it's not a miracle cure, it should be noted. To get best benefit, you should use compression stockings on it afterwards. However, even by itself it is helpful and that may be worthwhile to you.

It's another tool for the lipedema toolbox.


Monday, April 17, 2017

Creating a Healthcare Advocacy Notebook

If you've ever taken care of someone with a chronic health condition -- or if you've ever had a chronic health condition yourself -- you know that it can be challenging to deal with all the information, test results, doctor contact info, etc.

One of the best things you can do in this situation is to create a Health Advocacy Notebook where everything is gathered in one place. I learned this when I took care of my mother in her final years and I've had occasion to use it since for other family members (including myself) as well.

Directions

1. Start by getting a really good-quality notebook. Too big and it will be too cumbersome, but too small and there's not enough room. About an inch and a quarter is a good size.

2. Get a bunch of dividers. Get some that are just plain dividers and some dividers with pockets in them for keeping looseleaf handouts. Trust me, you'll want these. Medical people are always handing you loose pieces of paper and expecting you to keep track of them.

3. Start organizing the notebook in a way that makes sense for your situation. This will look different for everyone. Here are some specifics you might want to consider.

a. Overall summary of the person's situation. Basically, it's a cheat sheet for the hospital to have all your information in one place in a hurry during an emergency. Keep multiple copies so you can quickly give the hospital a copy and still have others. Be sure to keep the medications updated as these can change quickly. Include things like:
  • name
  • date of birth
  • address, cell phone number, and other contact information
  • all health conditions
  • list of current medications, dosages, and how often taken
  • history of major surgeries
  • next of kin and their contact information
  • power of healthcare attorney/living will information
b. Calendar. Many people choose the make the second section of the notebook a calendar. That way you can keep all the appointments in one place and available at a quick glance.

c. Blank paper for taking notes. It's so hard to remember questions for appointments; this section can help you keep track of those. Or it can be a great way to take notes during appointments and writing down the answers to those questions. You can go back and organize them later and decide what to keep.

d. Latest labs, scans, and test results. It can save time if you already have a copy of your latest test results instead of having to wait to access doctor files. Some people keep the actual images of x-rays or CT scans in the notebook but this can get too crowded for some. Use your judgment.

e. Specific medications or conditions. If you have an unusual condition or there is something unique about a medication you are on, a section on this could be very useful for quick reference.

f. Treatment side effects, alternative medications, or complementary therapies. Many people find it useful to keep sections on side effects or alternative therapies etc., whatever is most useful to you.

g. A page or two of plastic business card or trading card holders. In an emergency, you are often asked for the contact information for various doctors or labs. You can grab a business card from every doctor or therapist, stick it in the plastic holder, and always have contact info for each in one easy location. You'd be surprised how often you might need to find the address or phone number for some obscure doctor from several years ago. Keeping a card file can save a lot of time and effort. (These tend to be slippery so I prefer to keep these in the back.)

h. Keep a pen or two always in the notebook. That way you are always ready to take notes or write down questions and observations.

Summary

Health Advocacy Notebooks can be a powerful tool to helping yourself or others when health challenges present themselves.

It's easy to get overwhelmed when a loved one becomes a "frequent flyer" at the local Emergency Room, or to forget vital information if you get called in the middle of the night. If you have a grab-and-go notebook you are less likely to be caught unprepared. Keep the notebook in a bag with a sweater, some easy snacks, a book, etc. so that all you have to do is grab the bag on your way out the door in an emergency. That way, you will have supplies in case you are needed at the hospital for a while.

No two Health Advocacy Notebooks will look alike; each is going to be unique to your situation. Customize it to your own needs and it will serve you well. 

Friday, March 31, 2017

For Skin Yeast Treatment - Anti-Microbial Silver Cloth

As part of my recent health crisis, I ended up in the hospital and was introduced to a new product that might help many people with the skin yeast issues.

The product is Anti-Microbial Silver Cloth - a moisture-wicking fabric impregnated with anti-microbial silver. The one that was recommended to us by a wound nurse is "InterDry" made by Coloplast. There might be other brands available.

It has been remarkably successful so far. It should not be used by people with a known sensitivity to silver.

I will give further information on it in the future and update the Skin Yeast Manifesto, but wanted to give another option to people now.

Best wishes for good skin health,
Kmom

Blog Delay Due to Family Illness

Dear Readers,

You may have noticed an increase in the time between posts. We are experiencing a personal and family health crisis, and it will be a while before we have regular posts again.

We welcome prayers and well wishes, and will keep you updated as we can. My Blog is not ceasing to exist, it just needs to take a backseat for a little while.  People have visited this blog over 5 million times, and I am sure that we will have many more to come.

I have many more posts planned, and will get to them as recovery allows.  Comments will remain open by approval, and we will check them periodically.  I appreciate all good wishes.

Peace, blessings and good health to all.

Kmom

Friday, March 10, 2017

Skin-to-Skin Contact After Cesarean

Image by Nicole Monet Photography. Isn't this beautiful?
Here is yet another research study showing the benefits of skin-to-skin contact for babies and mothers, even during a cesarean. 

The study showed significantly lower rates of babies needing to be transferred to the NICU (Neonatal Intensive Care Unit) for observation when they had skin-to-skin contact with their mothers during a cesarean.

Other research shows that Skin-to-Skin Contact (SSC) improves breastfeeding rates. Although it noted that research quality needs improvement, the Cochrane Registry states:
Evidence supports the use of SSC to promote breastfeeding.
Skin-to-Skin Contact also has benefits beyond breastfeeding and fewer NICU transfers. An Australian study found that SSC and early breastfeeding decreased the rates of mothers experiencing post-partum hemorrhages. A study in Texas found that women who had SSC after cesareans reported less post-surgical pain. And a study from India found lower rates of infant hypothermia (low body temperature) after SSC.

Many hospitals around the country are now implementing skin-to-skin contact immediately after birth, and more and more are not differentiating between cesarean and vaginal births. Of course, SSC is not always possible under certain medical situations and there remain barriers to implementation, but most of the time it is indeed possible and many nurses, midwives, and doctors are leading the way in implementing these new policies.

Wouldn't it be nice to see ALL hospitals offering skin-to-skin contact immediately after birth, no matter the mode of birth? The World Health Organization  recommends SSC after a vaginal birth and "as soon as the mother is alert and responsive" after a cesarean. This is a big and important recommendation, and radical stuff for some hospitals. 

As long as medical circumstances allow and safety precautions are followed, Skin-to-Skin Contact should become standard of care everywhere, regardless of mode of birth. 


Reference

Nurs Womens Health. 2017 Feb - Mar;21(1):28-33. doi: 10.1016/j.nwh.2016.12.008. Influence of Immediate Skin-to-Skin Contact During Cesarean Surgery on Rate of Transfer of Newborns to NICU for Observation. Schneider LW, Crenshaw JT, Gilder RE. PMID: 28187837
We conducted an evidence-based practice project to determine if skin-to-skin contact immediately after cesarean birth influenced the rate of transfer of newborns to the NICU for observation. We analyzed data for 5 years (2011 through 2015) and compared the rates for the period before implementation of skin-to-skin contact with rates for the period after. The proportion of newborns transferred to the NICU for observation was significantly different and lower after implementing skin-to-skin contact immediately after cesarean birth (Pearson's χ2 = 32.004, df = 1, p < .001). These results add to the growing body of literature supporting immediate, uninterrupted skin-to-skin contact for all mother-newborn pairs, regardless of birth mode.

Sunday, February 26, 2017

Exercise Lowers the Risk for Gestational Diabetes in Women of Size

Image Credit: Stocky Bodies Image Library

Here is the abstract for a prospective randomized controlled study that found that regular exercise starting early in pregnancy can reduce the rate of gestational diabetes (GD) in "overweight" and "obese" women.

The study found that cycling 3x per week for at least 30 minutes each time cut the development of gestational diabetes from 40% down to 22%. That's a pretty impressive difference.

Note that the study did not involve special dietary programs or advice. This study was strictly about the effect of regular exercise on the development of GD. Most studies like this do not differentiate between dietary interventions and exercise interventions, but combine the two under "lifestyle intervention." Yet it's really useful to know what the effect of each is individually. This starts to answer that question.

Another good thing about the study was that it was done with Chinese women. Most GD studies are done on Caucasian women. We need more diversity in GD research, so this is a welcome addition.

Another strength of the study is that the intervention was started early in pregnancy. Most studies start exercise interventions in mid-pregnancy, somewhere in the second trimester. This one started it in the first trimester. It certainly seems logical that starting earlier in pregnancy would result in greater benefits than starting later.

This study also looked at the impact of regular exercise on GD in women of size. Often, exercise and GD studies do not look separately at higher-BMI women. In those studies, there seems to be less preventive impact for average-sized women. I strongly suspect that there is far more impact for higher-BMI women.

One weakness is that the study is fairly small. There were 150 women in the exercise group and 150 in the control group. I'd certainly like to see this study repeated with a larger group. However, it was a randomized controlled study, so that strengthens its findings.

Another weakness was that the groups tended to be more in the "overweight" rather than the "obese" category. I would like to see a study like this done where they see what the effect of regular exercise is differentiated by various classes of obesity.

While the study found slightly lower gestational weight gain among the exercise group, the difference was about 2 kg on average, or slightly less than 5 lbs. Not exactly an earth-shaking difference. Researchers need to focus less on the impact on weight gain, which is a fairly negligible difference in many of these studies, and more on more tangible outcomes like GD rates and other outcomes.

Do note that while the study found slightly lower rates of blood pressure issues, cesareans, and big babies among the exercise group, the difference did not rise to statistical significance. The confidence interval crossed 1.0 for all of these. A bigger study would be needed to know whether regular exercise truly affects those outcomes.

Final Thoughts

Most research around preventing complications in obese pregnancies centers around efforts that combine multiple interventions, but multiple interventions muddy the research waters.

There have been many trials that tried to lower complication rates in obese women through a combination of limiting weight gain, dietary interventions, caloric restriction, and exercise. Results have been highly inconsistent. Some have shown modest results, while others have shown little or no difference in outcomes.

I think they are trying to cast too broad a net. We need more studies that separate out individual factors more carefully so we can examine the benefits ─ and risks ─ more thoroughly. 

Each intervention has potential pitfalls that must be considered carefully. For example, aggressively limiting gain has many risks, including low-birthweight babies and prematurity. As a result, many researchers are re-thinking earlier calls for extremely restrictive gain or weight loss during pregnancy.

Studies on nutritional interventions to prevent GD are a mess, with a recent Cochrane review calling most of the evidence "low" or "very low" in quality. We don't really know if nutritional interventions like a low glycemic diet or caloric restriction are effective or even safe at this point.

Even exercise as an intervention for preventing GD has limited research with uneven quality. As noted above, exercise does not seem terribly effective for preventing GD when considering women of all sizes, but it may be more effective for women of size.

Some research suggests that regular exercise may have other benefits for high-BMI women, like cutting labor length. Still other research suggests that exercise may lower the risk for cesareans in first-time mothers of all sizes. However, exercise seems most useful in lowering the risk for GD. I would love to see further studies done on exercise alone, without caloric restriction or weight gain goals. I would like to see the studies be randomized and controlled, to start early in pregnancy or even before, to have more diverse study populations, and to further differentiate effects by class of obesity.

One potential concern has been whether starting an exercise program in pregnancy would lead to low-birth-weight or premature babies. This kept some doctors in the past from recommending exercise to obese pregnant women, but a recent meta-analysis of studies strongly suggests it does not increase the risk for prematurity.

Exercise is not a magic bullet that will prevent all complications in the pregnancies of women of size, but done reasonably, it does seem like it can moderately reduce the risk for certain complications like gestational diabetes. It certainly seems safer than strong weight gain restrictions or extreme caloric restriction.

I'm all for proactive health actions in people of size, and I think regular exercise is one of the most powerful actions women of size can take for pregnancy.

Let's see more research that more clearly delineates the influence of exercise vs. other factors and reassures us that exercise in pregnancy is indeed safe and beneficial for women of size.



Reference

Am J Obstet Gynecol. 2017 Feb 1. pii: S0002-9378(17)30172-2. doi: 10.1016/j.ajog.2017.01.037. [Epub ahead of print] A randomized clinical trial of exercise during pregnancy to prevent gestational diabetes mellitus and improve pregnancy outcome in overweight and obese pregnant women. Wang C, Wei Y, Zhang X, Zhang Y, Xu Q, Sun Y, Su S, Zhang L, Liu C, Feng Y, Shou C, Guelfi KJ, Newnham JP, Yang H. PMID: 28161306 DOI: 10.1016/j.ajog.2017.01.037
BACKGROUND: ...Regular exercise has the potential to reduce the risk of developing GDM and can be used during pregnancy; however, its efficacy remain controversial. At present, most exercise training interventions are implemented on Caucasian women and in the second trimester, and there is a paucity of studies focusing on overweight/obese pregnant women. OBJECTIVE: To test the efficacy of regular exercise in early pregnancy to prevent GDM in Chinese overweight/obese pregnant women. RESEARCH DESIGN AND METHODS: This was a prospective randomized clinical trial in which non-smoking women over 18 with a singleton pregnancy and met the criteria for overweight/obese status (BMI<28 kg/m2; obese, BMI>or = 28kg/m2) and an uncomplicated pregnancy at less than 12+6 weeks of gestation were randomly allocated to either exercise or a control group. Patients did not have contraindications to physical activity. Patients allocated to the exercise group were assigned to exercise 3 times per week (no less than 30 min/session with a rating of perceived exertion between 12-14) via a cycling program begun within 3 days of randomization until 37 weeks of gestation. Those in the control group continued their usual daily activities. Both groups received standard prenatal care, albeit without special dietary recommendations. The primary outcome was incidence of GDM. RESULTS: From December 2014 to July 2016, 300 singleton women at 10 gestational age and with a mean pre pregnancy BMI of 26.78 ± 2.75 kg/m2 were recruited. They were randomized into an exercise group (n=150) or a control group (150). 39 (26.0%) and 38 (25.3%) participants were obese in each group, respectively. (1) Women randomized to the exercise group had a significantly lower incidence of GDM (22.0% vs. 40.6%, p<0.001).(2) These women also had significantly (2) less gestational weight gain (4.08±3.02 kg vs. 5.92±2.58 kg, p<0.001) by 25 gestational weeks and at the end of pregnancy (8.38±3.65 kg vs. 10.47±3.33 kg, p<0.001), and (3) reduced insulin resistance levels (2.92±1.27 vs. 3.38 ±2.00, p=0.033) at 25 gestational weeks. Other secondary outcomes, including (4) gestational weight gain between 25 to 36 gestational weeks (4.55±2.06 kg vs. 4.59±2.31 kg, p=0.9), (5) insulin resistance levels at 36 gestational weeks (3.56±1.89 vs. 4.07±2.33, p=0.1), (6) hypertensive disorders of pregnancy (17.0% vs. 19.3%; odds ratio [OR], 0.854; 95% confidence interval [CI], 0.434-2.683, P=0.6), (7) cesarean delivery (except for scar uterus) (29.5% vs. 32.5%;OR, 0.869; 95% CI, 0.494 -1.529, P=0.6), (8) mean gestational age at birth (39.02 ± 1.29 vs. 38.89 ± 37 weeks gestation; P=0.5); (9) preterm birth (2.7% vs. 4.4%, OR, 0.600; 95% CI, 0.140-2.573, P=0.5), (10) macrosomia (defined as birth weight above 4000 g) (6.3% vs. 9.6%; OR, 0.624; 95% CI, 0.233-1.673, P=0.3) and (11) large for gestational age infants (14.3% vs. 22.8%; OR, 0.564; 95% CI, 0.284-1.121, P=0.1) were also lower in the exercise group compared to the control group, but without significant difference. However, infants born to women following the exercise intervention had a significantly lower birth weight compared with those born to women allocated to the control group (3345.27±397.07 vs. 3457.46±446.00, P=0.049). CONCLUSIONS: Cycling exercise initiated early in pregnancy and performed no less than 30 minutes, 3 times per week, is associated with a significant reduction in the frequency of GDM in overweight/obese pregnant women. And the decrease of GDM is very relevant to the less gestational weight gain before the mid-second trimester. Furthermore, there was no evidence that the exercise prescribed in this study increased the risk of preterm birth or reduced the mean gestational age at birth.

Sunday, February 5, 2017

Should Newly Diagnosed Diabetics Attempt to Lose Weight?


People with newly-diagnosed type 2 diabetes are faced with difficult decisions about weight loss.

They are often pushed to lose weight with the promise that this will improve their long-term health. The implication is that if they don't lose weight and change their lifestyle, they will surely have a heart attack and die sooner than later. Some care providers (and insurance companies) pressure new diabetics into weight loss programs through strong-arm tactics, shaming, and penalties.

However, the evidence is less than clear on the pros and cons of weight loss for diabetes. 

Short-term research seems to suggest benefits, but long-term research is much less clear. Some research even suggests potential harms. Let's talk about the benefits and risks.

The Look AHEAD Trial 

The Look AHEAD trial is the biggest example of the trade-off of pros and cons. It used an intensive life-style intervention to encourage intentional weight loss in type 2 diabetics. The trial was done with 5,145 people in 16 centers in the United States.

Details of the Study

Unlike most weight-loss trials, this one was long-term; major evaluations were done at 4 years and 8 years, but the study had a "median of 9.6 years of intervention and a maximal follow-up of 11.5 years." Participants were between the ages of 45 and 76 years old, and had to have a BMI over 25. 60% were women, and just over a third were from minority groups.

About half had a BMI under 35, with only about 22% from the heaviest group (BMI over 40). This means study participants skewed towards the lighter end of the BMI spectrum.

Participants were carefully selected to include those deemed most likely to lose weight successfully, including those who had prior intentional weight losses of more than 5% of bodyweight and who were highly motivated to lose weight. This detail is important because the trial does not represent a typical cross-section of the population and therefore may not be broadly applicable to those who do not fit the participant profile.

In this program, participants in the intensive lifestyle arm were asked to lose at least 10% of their body weight (with the hope that this would mean that study-wide, the group would lose on average a 7% weight loss goal). Participants were paid $100 each year to complete an annual weigh-in.

A lot of data from weight loss studies is pretty meaningless because of high drop-out rates. However, in this study, about 88% stayed through the eight-year post assessment. This relatively high completion rate gives more strength to this study.

The intensive lifestyle treatment arm was intense. For the first 4 months, participants were given meal-replacement shakes for 2 meals per day and snack bars for between meals. These were provided for free. They did eat one meal of real food per day but were encouraged to eat low-fat and low-calorie in that meal. After the first 4 months, participants were encouraged to continue using meal-replacement shakes for 1 meal per day for the rest of the first year and beyond, but it's not clear how many did or for how long.

After the first year, the focus was on maintaining weight loss and exercise levels, as well as offering additional support and interventions to those who did not achieve weight loss goals. 8-10 week "refresher" programs were offered each year to help refocus those who were regaining or who wanted additional help. So the program was not just about an initial weight loss program, but also about frequent re-do programs as needed.

Caloric goals were 1200-1500 calories for those less than 250 lbs. and 1500-1800 for those more than 250 lbs. Those who did not meet weight loss goals were encouraged to take Orlistat, a weight loss medication which was provided for free, although many did not choose to take it. They were also offered "more intensive behavioral interventions" to meet weight loss goals.

Participants were also encouraged to increase their exercise levels over time and had access to gym memberships, exercise equipment, and/or personal trainers. Participants were screened to make sure they were fit enough to do the exercise required so the study group did not include the sickest and most unfit diabetics. Participants were to slowly work up to a total of at least 175 minutes of exercise each week (about 3 hours per week), or about a half-hour of exercise per day, so the exercise requirements were not excessive. Most used walking as their preferred form of exercise.

Participants were asked to record food intake religiously and were encouraged to attend individual and group meetings regularly (individual meetings 1x/month and group meetings 3x/month for the first six months; individual meetings 1x/month and group meetings 2x/month after that). They were encouraged to weigh themselves daily at home and to weigh in at the group meetings. After the initial weight loss emphasis period was over, regular monthly meetings were encouraged and there were reminders about the program by email and texts. As noted previously, those not meeting weight loss goals had additional programs, behavioral interventions, and medications made available to them.

Weight Loss Results

The weight loss results from the study were mixed.

Overall, the intensive life-style intervention group managed to lose just 4.7% of their baseline weight at the end of 8 years. This is more than the diabetes support and education (DSE) group, which lost 2.1% in comparison, but it's not exactly impressive.

A 5% long-term loss is necessary to be deemed "clinically significant" in the medical literature. So by the evaluation calculated at 8 years, the study did not achieve a clinically significant weight loss.

However, when the study was terminated in 2012, the overall loss of the intervention group was about 6%, short of its goal of a 7% loss overall but squeaking by the 5% cutoff for clinical significance. This means the study authors could claim one of the very few long-term weight loss study success stories, but really, the "success" depends on when you looked at the data.

The fact that they were dancing around the 5% cutoff is more impressive than most long-term weight loss programs. Still, remember that this was among people pre-selected to be the most likely and highly motivated to lose weight.

The difference between the 4.7% at 8 years and the 6% at termination certainly suggests that there was a fair amount of yo-yoing going on. Did people really lose the weight and keep it off consistently, or were they bouncing all over the place constantly in the meantime? The most likely scenario was that there was a significant initial loss, followed by the typical slow regain, which the participants then fought by once again diving back into weight loss efforts, over and over again. However, we'd need access to the data of all the participants over the entire study length to confirm how often that was the pattern.

One of the more notable and highly publicized results of the study was that 50.3% of the intensive lifestyle group managed to lose 5% or more and 26.9% managed to lose 10% or more of their baseline weight at 8 years. Again, many of these were probably bouncing around rather than achieving a sustained loss, but even so, that's a fair success story.

But let's be fair. Half of the intervention group did manage to lose more than 5% of their baseline weight, but of course this also means that half did not, despite the very intensive interventions. Slightly more than one-fourth managed to lose at least 10% of their baseline weight, but of course, that also means that three-quarters of the intensive treatment group did not. So while the success rates were higher than most long-term studies, they are hardly a ringing endorsement of the success rates of weight loss.

The 8-year follow-up study also showed that 26.4% of intensive lifestyle participants had gained weight over their baseline weights. That's significant; over one-fourth of the weight-loss group actually ended up heavier than they started.

However, of those who lost at least 10% of their baseline weight in the first year, "only" 14% had gained weight over their baselines by year 8. This means that those who lost the most at first were less likely than others to end up heavier than they began.

The study shows that significant weight loss of around 5% is possible for some diabetics with intensive interventions. However, it also showed that even with intensive interventions, extensive weight loss was very difficult and do not work long-term for many. It seems to have translated more to a lot of yo-yoing around. Whether those people were better off for the yo-yoing is an ongoing question.

Frankly, I'd love to see more reporting on the group of those who yo-yo'd around and those who ended up heavier than they started. What were their outcomes? That's the real question for those of us with strong histories of weight cycling; would we be better off trying to lose weight, even if we regained it, or are we worse off yo-yoing around?

Still, the Look AHEAD study is often touted as proof of the importance of a weight loss for new diabetics and a refutation of the criticism that weight loss is usually unsuccessful. Half of the intensive lifestyle participants managed around a 5% loss, after all, and a quarter managed a 10%+ loss.

On the other hand, one analysis suggested that the Look AHEAD authors were putting too much of a positive spin on weight loss in the study and concluded:
The NEJM article states that this study represents that the “weight loss achieved in the intervention group is representative of the best that can be achieved by current lifestyle approaches.” If so, it’s a pretty meager showing for a highly-motivated population receiving an Über-Intensive-Lifestyle Intervention. These results should be the starting point for a broad re-assessment of behavioral lifestyle interventions...A ‘scientific society’ should confront the data and lead the discussion for re-assessment instead of putting the proverbial lipstick on a pig.
Health Results

What's most important is not how much weight people lost or didn't lose, but rather how this affected their health. The answer is that it's a mixed bag.

The Good News

Those who lost weight and managed to keep it off in the Look AHEAD trial did show some health improvement, as study promoters loudly proclaimed afterwards. That is very good news for those who lost weight.

They had improved blood sugar and lipid levels, less sleep apnea, less liver fat, less incontinence, improved sexual function, and better physical mobility. That's no small feat.

Some did reduce their risk for chronic kidney disease, which is quite important since kidney disease is a major issue for diabetics.

These health improvements are nothing to sneer at and do make a case for considering weight loss after a diagnosis of diabetes.

The So-So News

Newly diagnosed diabetics are often pushed into weight loss with the idea that this can "cure" their diabetes, so it's important to look at this outcome as well. However, "cure" is the wrong word; "remission" is a more appropriate word for what usually happens.

Some who lost weight in the Look AHEAD program did have some remission of their diabetes status in the first four years, at least for a while. However, the study noted that "absolute remission rates were modest" because only 3.5% managed to achieve and sustain diabetes remission for four years.

So while long-term diabetes remission was possible, it was achieved by only a few, even at only four years. Most often, diabetes remission was a temporary state of affairs, if it happened at all, and definitely not a "cure."

However, let's not forget that for some, blood sugar levels and other health markers did improve, even if it didn't result in total remission, so the focus shouldn't be only on remission.

The Mostly Bad News

The most important result was that while the trial resulted in modest health improvements, intentional weight loss did NOT reduce the rate of cardiovascular events in this group. 

This was a major disappointment for the study, especially given that its main hypothesis was that losing weight would result in fewer major events such as heart attacks or death.

Unfortunately, the intervention had NO effect on events like heart attacks, stroke, or death due to cardiovascular causes. In fact, the investigators terminated the study two years early because the lack of effect on the most important endpoints was so remarkable.

Critics contend that the lack of effect was seen because the "Diabetes Support and Education" (DSE) control group developed much less heart disease than the authors predicted. Many attributed this to the fact that many in the control group were put on statin medications, but whether this was the source of the difference is debatable.

On the other hand, a recent secondary analysis of the data showed that those who lost at least 10% of their initial weight did have some improvement in cardiovascular outcomes. Those who lost at least 10% of their baseline weight in the first year had a 21% reduced risk of the primary outcome (heart attacks, strokes, death from heart disease, or hospitalization for angina) and a 24% reduced risk of the secondary outcome (congestive heart failure, medical interventions like bypasses etc., and total mortality). A significant improvement in fitness levels also improved secondary outcomes but just missed achieving clinical significance in primary outcomes.

These are not huge improvements, mind, but they are improvements, so many doctors still feel that it's worth promoting significant weight loss in newly diagnosed diabetics, aiming for at least a 10% loss.

On the other hand, there were other disappointments. Weight loss did not lessen the rate of development of Atrial Fibrillation, an irregular heartbeat that can lead to strokes and other problems. That's another major disappointment.

Nor did the Look AHEAD trial interventions improve cognitive functioning. In fact, the authors noted:
There was some evidence of trends for differential intervention effects showing modest harm in [Intensive Lifestyle Intervention] participants with greater body mass index and in individuals with a history of cardiovascular disease.
That's a little alarming and should be investigated more. Quality of life matters. Based on what doctors have been saying for years, one would expect that a significant loss should improve cognitive functioning, not harm it. This definitely needs further research.

Another recent follow-up from the Look AHEAD trial also showed that those who regained weight or were weight cyclers in the trial had worse physical functioning scores by the end of the trial. That's a big deal. For some the intervention was clearly harmful.

And some research suggests that those who lost weight may also have issues with bone loss. The last thing diabetics need to add is more health problems like easily broken bones or osteoporosis.

So, bottom line, if you were part of the roughly one-fourth who lost a lot of weight at the beginning of the trial and were able to maintain that loss, there might have been some very modest improvements in cardiovascular outcomes, but certainly not the scope that they were hoping for.

For most who did not have a huge difference in weight, the intervention did not offer any improvement in cardiovascular outcomes or death rates.

And if you were part of the group that regained or were significant weight cyclers, you might actually have ended up worse off than you started.

So it seems the outcome depends on which group you were in. How do you predict which group you would likely be a part of? That's the $64,000 question.

Other Studies Like Look AHEAD

Of course, the Look AHEAD study is not the only one out there that has looked at weight loss and diabetes. It's just the one with the most-closely examined data.

Generally speaking, several studies show that for those who can maintain their weight loss, they have benefits like lower blood sugar and needing fewer medications. But what about those who do not maintain the weight loss?

One 2008 study found that even those who largely regained an initial weight loss had better glycemic control and blood pressure than those who were weight-stable after 3 years. (In this study, only 12.2% of newly diagnosed diabetics lost a clinically significant amount of weight, and most regained it all by the end of the study.)

However, other studies have not always found benefits if weight is regained. A 2015 study found that even only a partial regain after initial weight loss largely wiped out any improvements in blood sugar regulation.

In addition, a recent major Scottish study found that while sustained weight loss improved blood glucose control, strong weight variability was associated with poorer outcomes and poorer survival rates among recently-diagnosed diabetics. The authors concluded:
Our results suggest that weight loss or being weight stable with little weight variability early after diabetes diagnosis are associated with better glycaemic control...With respect to mortality and cardiovascular outcomes, although weight change at 2 years was a weak predictor, major weight variability appeared to be the more relevant factor.
And a recent long-term Danish study of newly-diagnosed diabetics also found that long-term intentional weight loss in diabetics did not improve all-cause mortality or cardiovascular-related morbidity and mortality in those followed for 19 years after diagnosis. The best prognosis was in those who maintained their weight.

So the idea that intentional weight loss automatically improves outcomes and prolongs lives among diabetics certainly can be questioned. It seems to help improve glucose control for those who lose a substantial amount of weight and keep it off long-term, but for those who yo-yo up and down or who regain the weight, the benefits are far more questionable and may even be harmful.

Summary

Most diabetes guidelines recommend lifestyle intervention (including an emphasis on losing weight as well as increasing exercise) for newly diagnosed diabetics.

Diabetes studies often state strongly weight-centric things like, "Weight management may be the most important therapeutic task for most obese Type 2 diabetic individuals."

But should all newly-diagnosed diabetics attempt to lose weight? Would some be better off maintaining their weight and working on fitness or other goals? This is a key question in the treatment of diabetes. Frankly, the research is debatable.

Short-term studies often show improvements in various risk factors and blood sugar regulation, sometimes even if weight is regained. That's no small accomplishment. However, many of these studies are notoriously brief and small in scope, often lasting a year or less. Benefits are often lost when participants are analyzed more long-term. You really have to take the short, small studies with a large grain of salt.

Moreover, most interventions in weight loss and diabetes studies do not result in clinically significant weight loss (more than 5%). One review concluded:
The majority of lifestyle weight-loss interventions in overweight or obese adults with type 2 diabetes resulted in weight loss <5% and did not result in beneficial metabolic outcomes.
Larger losses (greater than 10%) seem to have the most benefit long-term, but most participants do not manage such levels of weight loss long-term. The Look AHEAD study did not reach even its 7% weight loss goal, despite quite intensive interventions and a focus on those most likely to succeed. The same review listed above concluded:
Weight loss for many overweight or obese individuals with type 2 diabetes might not be a realistic primary treatment strategy for improved glycemic control.
The bottom line for those who have been diagnosed with type 2 diabetes is that there are no clear answers regarding weight loss. There might be some benefits from losing weight if it is sustained, but then again, there might be some risks as well, including increased fatness for those who regain weight or experience weight cycling. This might negate the short-term benefits of weight loss, especially since weight loss is negligible for most in terms of the most important endpoints like heart attacks, stroke, and death.

Frankly, we need better evidence to guide us. Studies need to:
  • Last at least multiple years rather than months ─ at least 5 years is best
  • Need to have sufficient participants to have the power to show clinically meaningful results 
  • Need to differentiate between weight loss and exercise instead of lumping their effects together in analysis; it may be that increased exercise is far more important for blood sugar regulation and long-term health than weight loss itself (or vice versa)
  • Need to investigate whether there are sub-groups who benefit most or who are most harmed by weight loss attempts, instead of assuming similar effects among whole groups
  • Need to focus on weight cyclers in particular and see what the relative benefits and risks are for this group, since this is a very likely outcome for many 
So, the question becomes ─ if you are diabetic, do you try to lose weight in hopes that you would be one of the lucky ones who lose more than 10% of weight and keep it off? Or would you be more likely to be among those who regain or cycle? 

New diabetics have several key questions they must ask themselves. They should take a frank and honest look at their own habits, at their weight history, and at their lifestyle. They need to consider whether they think they could fall into that 10% sustained weight loss group, or whether they would be more likely to end up in the weight cyclers or weight gain groups.

In the end, the decision on whether or not to pursue weight loss should always be up to the patient. Patients can be advised of the potential benefits of weight loss, but they must also be advised of the potential risks of weight loss as well.

Guidelines from the American Diabetes Association push weight loss very strongly, but they do have some language tacitly acknowledging (in a rather condescending way) that the decision is up to the patient (my emphasis):
Diet, physical activity, and behavioral therapy designed to achieve 5% weight loss should be prescribed for overweight and obese patients with type 2 diabetes ready to achieve weight loss.
Those people who choose weight loss should be given every support possible, but without making participants' sense of self-worth dependent on their results. In addition, programs need to be extremely careful that they are not promoting eating-disordered behaviors or destroying participants' self-esteem. Many people with eating disorders developed them on well-meaning weight loss programs like these.

Those people who choose not to undertake weight loss should not be treated badly by care providers or penalized financially by insurance companies. Weight loss is a medical intervention, and like any other intervention, patients have the right to informed consent and should be free to accept or decline it without penalty.

Of course, it's always important to point out that you can fine-tune dietary intake and increase exercise without weight loss as your goal. This is the Health At Every Size® approach. Diabetics don't have to choose only between a weight-loss-at-any-cost approach or completely ignoring good nutrition and exercise (as many doctors wrongly assume a HAES® patient will do). There is a happy medium that emphasizes self-care without emphasizing the scale.

Some research suggests that a Mediterranean-style diet (mostly plant-based, low-to-moderate carbohydrate intake, with an emphasis on whole grains, nuts, and healthy fats) may be advantageous to diabetics. More research is needed, but initial studies are promising.

In addition, some people with blood sugar issues find that giving up certain types of foods they are sensitive to (like gluten, dairy, corn, or certain fruits and vegetables) changes their blood sugar responses without necessarily affecting their weight or calorie intake. This is another option some people may wish to explore.

Most importantly, increased fitness has been shown to improve blood sugar levels, insulin sensitivity, and quality of life in diabetics, especially when a combination of aerobic and resistance exercise is used. Thus, an emphasis on exercise, even without concurrent weight loss, may improve outcomes for diabetics.

Don't let diabetes education programs or doctors make you feel like your only choice after a diabetes diagnosis is weight loss. Whether you wish to participate in a weight loss program is your choice.

You can absolutely pursue weight loss if you feel like that is the right option for you, and there are many programs that will help you towards this goal if that's what you want. Just ask for them.

But if you don't wish to hop on the weight loss roller-coaster again, rest assured that there are things besides weight loss you can do to improve your outcomes.

My Take

I'm sure many readers are wondering if I'm writing about this topic from personal experience. No, I'm not diabetic, but there is an extremely strong history of diabetes on one side of my biological family so it is likely I will face a diagnosis at some point. Genetics is not destiny, of course, but it does point to strong probability. As a result, I look at studies like these periodically and debate what would be the best course for me if I did get diabetes at some point.

Personally, my feeling is that weight-loss decisions in diabetes should be made on a case-by-case basis rather than a blanket policy across the board. This is where I differ from experts in both the diabetes field and the size-acceptance field, who tend to be all-or-nothing ("everyone should lose weight" or "no one should ever try to lose weight") about the issue. I say, look at your personal history and habits and use those to guide your decision. 

For those who were once a "normal" BMI and who have simply gained weight due to age and/or poor habits, a weight loss emphasis might make sense. Anecdotally, these seem to be the people who are most successful at long-term weight loss and who benefit the most from it. It's just a returning to what is normal for their body.

Similarly, those who have had poor nutritional habits or an unhealthy relationship with food should be encouraged to improve those, since it is likely that improving these could well result in weight loss and improvements in blood sugar status.

Those who have indulged in foolish or trendy dieting practices (the "grapefruit diet" or similar programs) instead of sensible, moderate approaches might also benefit from trying again with a sensible plan. Whatever changes you make have to be sustainable, not something you do for a little while and then stop. 

However, I strongly suspect that major weight loss efforts are actually counter-productive for those who have been heavy most of their lives, have a long history of weight cycling, and who generally have reasonable habits and intake.

A lot depends on the person's personal weight and dieting history. If a person has a long history of weight cycling and obesity despite reasonable habits, I question the wisdom of subjecting that person to yet another round of dieting or ever-increasing caloric restriction. If they have a history of ending up heavier than they began after most diets, it seems far more likely that the intervention would harm rather than help, so why take that risk? In particular I question the likelihood of sustained weight loss for people who have biological reasons for fatness like lipedema or PCOS.

Also consider the psychological effects of an emphasis on weight loss; if it would harm self-esteem or re-trigger eating-disordered behaviors, then the potential benefits of weight loss may be far overshadowed by the potential harms. I strongly question the use of diets in this context. Eating disorders are very serious, and the potential for harm here is quite high. 

This doesn't mean that there is no role for lifestyle counseling. Habits can be relevant. But emphasis should be placed on HABITS and not on the scale, and lab results and the person's health should guide changes. Furthermore, recent research shows that more aggressive management of medications early in the course of diabetes may improve outcomes. To me, a more sensible course for many might be:
  • To encourage an increase in both fitness and strength
  • To focus on optimization of lab results through medication management and exercise
  • To consult with a medical nutritional specialist who does not focus on weight loss or caloric restriction but rather on refining nutritional habits and discovering "trigger" foods that cause high blood sugar or insulin levels
  • To find ways of living that are sustainable long-term and which do not measure a person's worth based on the scale
  • [For those who are not yet diabetic but have an extremely strong family history of diabetes (or those who are in the "pre-diabetes" range), to consider medications like metformin as a proactive prevention treatment since research shows that this can lower the risk for diabetes even without weight loss]
Traditional medicine needs to step away from the "shame and blame" model of diabetes management. It needs to acknowledge that genetics play a stronger role in the development of type 2 diabetes and obesity than is generally recognized, and that while lifestyle habits can be relevant, they are not the whole story.

Only when medicine does this will it be able to move beyond the simplistic "every diabetic should lose weight" mentality. While it may be helpful to some, this approach is not helpful to many and may even be harmful to some.

The truth is that the best course of treatment for new diabetics is probably best individualized for each person, based on their personal history and circumstances. And as always, the final decision should be left up to the individual. 



References

Look AHEAD Studies

N Engl J Med. 2013 Jul 11;369(2):145-54. doi: 10.1056/NEJMoa1212914. Epub 2013 Jun 24. Cardiovascular effects of intensive lifestyle intervention in type 2 diabetes. Look AHEAD Research Group, Wing RR, Bolin P, et al. PMID: 23796131. Full text available here.
BACKGROUND: Weight loss is recommended for overweight or obese patients with type 2 diabetes on the basis of short-term studies, but long-term effects on cardiovascular disease remain unknown. We examined whether an intensive lifestyle intervention for weight loss would decrease cardiovascular morbidity and mortality among such patients. METHODS: In 16 study centers in the United States, we randomly assigned 5145 overweight or obese patients with type 2 diabetes to participate in an intensive lifestyle intervention that promoted weight loss through decreased caloric intake and increased physical activity (intervention group) or to receive diabetes support and education (control group). The primary outcome was a composite of death from cardiovascular causes, nonfatal myocardial infarction, nonfatal stroke, or hospitalization for angina during a maximum follow-up of 13.5 years. RESULTS: The trial was stopped early on the basis of a futility analysis when the median follow-up was 9.6 years. Weight loss was greater in the intervention group than in the control group throughout the study (8.6% vs. 0.7% at 1 year; 6.0% vs. 3.5% at study end). The intensive lifestyle intervention also produced greater reductions in glycated hemoglobin and greater initial improvements in fitness and all cardiovascular risk factors, except for low-density-lipoprotein cholesterol levels. The primary outcome occurred in 403 patients in the intervention group and in 418 in the control group (1.83 and 1.92 events per 100 person-years, respectively; hazard ratio in the intervention group, 0.95; 95% confidence interval, 0.83 to 1.09; P=0.51). CONCLUSIONS: An intensive lifestyle intervention focusing on weight loss did not reduce the rate of cardiovascular events in overweight or obese adults with type 2 diabetes.
Obesity (Silver Spring). 2014 Jan;22(1):5-13. doi: 10.1002/oby.20662. Eight-year weight losses with an intensive lifestyle intervention: the look AHEAD study. Look AHEAD Research Group. PMID: 24307184. Full text here.
OBJECTIVE: To evaluate 8-year weight losses achieved with intensive lifestyle intervention (ILI) in the Look AHEAD (Action for Health in Diabetes) study...RESULTS: All participants had the opportunity to complete 8 years of intervention before Look AHEAD was halted in September 2012; ≥88% of both groups completed the 8-year outcomes assessment. ILI and DSE participants lost (mean ± SE) 4.7% ± 0.2% and 2.1 ± 0.2% of initial weight, respectively (P < 0.001) at year 8; 50.3% and 35.7%, respectively, lost ≥5% (P < 0.001), and 26.9% and 17.2%, respectively, lost ≥10% (P < 0.001)...CONCLUSIONS: Look AHEAD's ILI produced clinically meaningful weight loss (≥5%) at year 8 in 50% of patients with type 2 diabetes and can be used to manage other obesity-related co-morbid conditions.
Lancet Diabetes Endocrinol. 2016 Nov;4(11):913-921. doi: 10.1016/S2213-8587(16)30162-0. Epub 2016 Aug 30. Association of the magnitude of weight loss and changes in physical fitness with long-term cardiovascular disease outcomes in overweight or obese people with type 2 diabetes: a post-hoc analysis of the Look AHEAD randomised clinical trial. Look AHEAD Research Group. PMID: 27595918
...In this observational, post-hoc analysis, we examined the association of magnitude of weight loss and fitness change over the first year with incidence of cardiovascular disease. The primary outcome of the trial and of this analysis was a composite of death from cardiovascular causes, non-fatal acute myocardial infarction, non-fatal stroke, or admission to hospital for angina. The secondary outcome included the same indices plus coronary artery bypass grafting, carotid endartectomy, percutaneous coronary intervention, hospitalisation for congestive heart failure, peripheral vascular disease, or total mortality. We adjusted analyses for baseline differences in weight or fitness, demographic characteristics, and risk factors for cardiovascular disease...FINDINGS: For the analyses related to weight change, we excluded 311 ineligible participants, leaving a population of 4834; for the analyses related to fitness change, we excluded 739 participants, leaving a population of 4406. In analyses of the full cohort (ie, combining both study groups), over a median 10·2 years of follow-up (IQR 9·5-10·7), individuals who lost at least 10% of their bodyweight in the first year of the study had a 21% lower risk of the primary outcome (adjusted hazard ratio [HR] 0·79, 95% CI 0·64-0·98; p=0·034) and a 24% reduced risk of the secondary outcome (adjusted HR 0·76, 95% CI 0·63-0·91; p=0·003) compared with individuals with stable weight or weight gain. Achieving an increase of at least 2 metabolic equivalents in fitness change was associated with a significant reduction in the secondary outcome (adjusted HR 0·77, 95% CI 0·61-0·96; p=0·023) but not the primary outcome (adjusted HR 0·78, 0·60-1·03; p=0·079). In analyses treating the control group as the reference group, participants in the intensive lifestyle intervention group who lost at least 10% of their bodyweight had a 20% lower risk of the primary outcome (adjusted HR 0·80, 95% CI 0·65-0·99; p=0·039), and a 21% lower risk of the secondary outcome (adjusted HR 0·79, 95% CI 0·66-0·95; p=0·011); however, change in fitness was not significantly associated with a change in the primary outcome. INTERPRETATION: The results of this post-hoc analysis of Look AHEAD suggest an association between the magnitude of weight loss and incidence of cardiovascular disease in people with type 2 diabetes. These findings suggest a need to continue to refine approaches to identify individuals who are most likely to benefit from lifestyle interventions and to develop strategies to improve the magnitude of sustained weight loss with lifestyle interventions.
Obes Sci Pract. 2015 Oct;1(1):12-22. Epub 2015 Sep 14. Body Weight Dynamics Following Intentional Weight Loss and Physical Performance: The Look AHEAD Movement and Memory Study. Beavers KM, Neiberg RH, Houston DK, Bray GA, Hill JO, Jakicic JM, Johnson KC, Kritchevsky SB. PMID: 27453790
OBJECTIVE: To explore the impact of body weight change following intentional weight loss on measures of physical performance in adults with diabetes. DESIGN AND METHODS: 450 individuals with type 2 diabetes (age: 59.0±6.9 years, BMI: 35.5±5.9 kg/m2) who participated in the Look AHEAD Movement and Memory Study and lost weight one year after being randomized to an intensive lifestyle intervention were assessed. Body weight was measured annually, and participants were categorized as continued losers/maintainers, regainers, or cyclers based on a ±5% annual change in weight. Objective measures of physical performance were measured at the year 8/9 visit. RESULTS: Forty-four, 38 and 18% of participants were classified as regainers, cyclers, and continued losers/maintainers. In women, weight cycling and regain was associated with worse follow-up expanded physical performance battery score (1.46±0.07 and 1.48±0.07 vs. 1.63±0.07, both p≤0.02) and slower 20-meter walking speed (1.10±0.04 and 1.08±0.04 m/s vs. 1.17±0.04 m/s, both p<0.05) compared to continued or maintained weight loss. Male cyclers presented with weaker grip strength compared to regainers or continued losers/maintainers (30.12±2.21 kg versus 34.46±2.04 and 37.39±2.26 kg; both p<0.01). CONCLUSIONS: Weight cycling and regain following intentional weight loss in older adults with diabetes was associated with worse physical function in women and grip strength in men.
J Am Geriatr Soc. 2017 Jan 9. doi: 10.1111/jgs.14692. [Epub ahead of print] Effect of a Long-Term Intensive Lifestyle Intervention on Cognitive Function: Action for Health in Diabetes Study. Rapp SR, et al.; Look AHEAD Research Group. PMID: 28067945
OBJECTIVES: To assess whether randomization to 10 years of lifestyle intervention to induce and maintain weight loss improves cognitive function...RESULTS: Assignment to lifestyle intervention was not associated with significantly different overall (P = .10) or domain-specific (all P > .10) cognitive function than assignment to diabetes support and education. Results were fairly consistent across prespecified groups, but there was some evidence of trends for differential intervention effects showing modest harm in ILI in participants with greater body mass index and in individuals with a history of cardiovascular disease. Cognitive function was not associated with changes in weight or fitness (all P > .05). CONCLUSION: A long-term behavioral weight loss intervention for overweight and obese adults with diabetes mellitus was not associated with cognitive benefit.
Studies Other Than Look AHEAD

J Acad Nutr Diet. 2015 Sep;115(9):1447-63. doi: 10.1016/j.jand.2015.02.031. Epub 2015 Apr 29. Lifestyle weight-loss intervention outcomes in overweight and obese adults with type 2 diabetes: a systematic review and meta-analysis of randomized clinical trials. Franz MJ, Boucher JL, Rutten-Ramos S, VanWormer JJ. PMID: 25935570
...A systematic review and meta-analysis was undertaken to answer the following primary question: In overweight or obese adults with type 2 diabetes, what are the outcomes on hemoglobin A1c (HbA1c) from lifestyle weight-loss interventions resulting in weight losses greater than or less than 5% at 12 months? Secondary questions are: What are the lipid (total cholesterol, low-density lipoprotein cholesterol, high-density lipoprotein cholesterol, and triglycerides) and blood pressure (systolic and diastolic) outcomes from lifestyle weight-loss interventions resulting in weight losses greater than or less than 5% at 12 months? And, what are the weight and metabolic outcomes from differing amounts of macronutrients in weight-loss interventions? Inclusion criteria included randomized clinical trial implementing weight-loss interventions in overweight or obese adults with type 2 diabetes, minimum 12-month study duration, a 70% completion rate, and an HbA1c value reported at 12 months. Eleven trials (eight compared two weight-loss interventions and three compared a weight-loss intervention group with a usual care/control group) with 6,754 participants met study criteria. At 12 months, 17 study groups (8 categories of weight-loss intervention) reported weight loss <5% of initial weight (-3.2 kg [95% CI: -5.9, -0.6]). A meta-analysis of the weight-loss interventions reported nonsignificant beneficial effects on HbA1c, lipids, or blood pressure. Two study groups reported a weight loss of ≥5%: a Mediterranean-style diet implemented in newly diagnosed adults with type 2 diabetes and an intensive lifestyle intervention implemented in the Look AHEAD (Action for Health in Diabetes) trial. Both included regular physical activity and frequent contact with health professionals and reported significant beneficial effects on HbA1c, lipids, and blood pressure. Five trials (10 study groups) compared weight-loss interventions of differing amounts of macronutrients and reported nonsignificant differences in weight loss, HbA1c, lipids, and blood pressure. The majority of lifestyle weight-loss interventions in overweight or obese adults with type 2 diabetes resulted in weight loss <5% and did not result in beneficial metabolic outcomes. A weight loss of >5% appears necessary for beneficial effects on HbA1c, lipids, and blood pressure. Achieving this level of weight loss requires intense interventions, including energy restriction, regular physical activity, and frequent contact with health professionals. Weight loss for many overweight or obese individuals with type 2 diabetes might not be a realistic primary treatment strategy for improved glycemic control. Nutrition therapy for individuals with type 2 diabetes should encourage a healthful eating pattern, a reduced energy intake, regular physical activity, education, and support as primary treatment strategies.
Obes Res Clin Pract. 2015 May-Jun;9(3):266-73. doi: 10.1016/j.orcp.2014.09.003. Epub 2014 Oct 5. Effects of weight regain following intentional weight loss on glucoregulatory function in overweight and obese adults with pre-diabetes. Beavers KM, Case LD, Blackwell CS, Katula JA, Goff DC Jr, Vitolins MZ. PMID: 25293586
OBJECTIVE: To assess the extent to which initial, intentional weight loss-associated improvements in glucose tolerance and insulin action are diminished with weight regain. METHODS: 138 overweight and obese (BMI: 32.4±3.9kg/m(2)), adults (59.0±9.7 years), with pre-diabetes were followed through a 6-month weight loss intervention and subsequent 18-month weight maintenance period, or usual care control condition. Longitudinal change in weight (baseline, 6, 24 months) was used to classify individuals into weight pattern categories (Loser/Maintainer (LM), n= 50; Loser/Regainer (LR), n=51; and Weight Stable (WS), n=37). Fasting plasma glucose (FPG), insulin, and insulin resistance (HOMA-IR) were measured at baseline, 6, 12, 18 and 24 months and model adjusted changes, by weight pattern category, were assessed. RESULTS: LMs and LRs lost 8.3±4.7kg (8.7±4.5%) and 9.6±4.7kg (10.2±4.7%) during the first 6 months, respectively. LM continued to lose 1.1±3.4kg over the next 18 months (9.9±6.5% reduction from baseline; p<0.05), while LRs regained 6.5±3.7kg (3.3±5.3% reduction from baseline; p<0.05). Weight change was directly associated with change in all DM risk factors (all p<0.01). Notably, despite an absolute reduction in body weight (from baseline to 24 months) achieved in the LR group, 24-month changes in FPG, insulin, and HOMA-IR did not differ between WS and LR groups. Conversely, LM saw sustained improvements in all measured DM risk factors. CONCLUSIONS: Significant weight loss followed by weight loss maintenance is associated with sustained improvements in FPG, insulin, and HOMA-IR; conversely, even partial weight regain is associated with regression of initial improvements in these risk factors towards baseline values.
BMJ Open. 2016 Jul 26;6(7):e010836. doi: 10.1136/bmjopen-2015-010836. Patterns of weight change after the diagnosis of type 2 diabetes in Scotland and their relationship with glycaemic control, mortality and cardiovascular outcomes: a retrospective cohort study. Aucott LS, Philip S, Avenell A, Afolabi E, Sattar N, Wild S; Scottish Diabetes Research Network Epidemiology Group. PMID: 27466237. Full free text found here.
OBJECTIVES: To determine weight change patterns in Scottish patients 2 years after diagnosis of type 2 diabetes and to examine these in association with medium-term glycaemic, mortality and cardiovascular outcomes...PARTICIPANTS: 29 316 overweight/obese patients with incident diabetes diagnosed between 2002 and 2006 were identified with relevant information for ≥2 years. RESULTS: By 2 years, 36% of patients had lost ≥2.5% of their weight. Increasing age, being female and a higher body mass index at diagnosis were associated with larger proportions of weight lost (p<0.001). Multivariable modelling showed that inadequate glycaemic control at 2 years was associated with being younger at baseline, being male, having lower levels of obesity at diagnosis, gaining weight or being weight stable with weight change variability, and starting antidiabetic medication. While weight change itself was not related to mortality or cardiovascular outcomes, major weight variability was independently associated with poorer survival and increased cardiovascular outcome risks, as was deprivation. CONCLUSIONS: Our results suggest that weight loss or being weight stable with little weight variability early after diabetes diagnosis, are associated with better glycaemic control and we identified groups less able to lose weight. With respect to mortality and cardiovascular outcomes, although weight change at 2 years was a weak predictor, major weight variability appeared to be the more relevant factor.
PLoS One. 2016 Jan 25;11(1):e0146889. doi: 10.1371/journal.pone.0146889. eCollection 2016. Intentional Weight Loss and Longevity in Overweight Patients with Type 2 Diabetes: A Population-Based Cohort Study. Køster-Rasmussen R, Simonsen MK, Siersma V, Henriksen JE, Heitmann BL, de Fine Olivarius N. PMID: 26808532
OBJECTIVE: This study examined the influence of weight loss on long-term morbidity and mortality in overweight (BMI≥25 kg/m2) patients with type 2 diabetes, and tested the hypothesis that therapeutic intentional weight loss supervised by a medical doctor prolongs life and reduces the risk for cardiovascular disease in these patients. METHODS: This is a 19 year cohort study of patients in the intervention arm of the randomized clinical trial Diabetes Care in General Practice. Weight and prospective intentions for weight loss were monitored every third month for six years in 761 consecutive patients (≥40 years) newly diagnosed with diabetes in general practices throughout Denmark in 1989-92. Multivariable Cox regression was used to estimate the association between weight change during the monitoring period (year 0 to 6) and the outcomes during the succeeding 13 years (year 6 to 19) in 444 patients who were overweight at diagnosis and alive at the end of the monitoring period (year 6). The analysis was adjusted for age, sex, education, BMI at diagnosis, change in smoking, change in physical activity, change in medication, and the Charlson comorbidity 6-year score. Outcomes were from national registers. RESULTS: Overall, weight loss regardless of intention was an independent risk factor for increased all-cause mortality (P<0.01). The adjusted hazard ratio for all-cause mortality, cardiovascular mortality, and cardiovascular morbidity attributable to an intentional weight loss of 1 kg/year was 1.20 (95%CI 0.97-1.50, P = 0.10), 1.26 (0.93-1.72, P = 0.14), and 1.06 (0.79-1.42, P = 0.71), respectively. Limiting the analysis to include only those patients who survived the first 2 years after the monitoring period did not substantially change these estimates. A non-linear spline estimate indicated a V-like association between weight change and all-cause mortality, suggesting the best prognosis for those who maintained their weight. CONCLUSIONS: In this population-based cohort of overweight patients with type 2 diabetes, successful therapeutic intentional weight loss, supervised by a doctor over six years, was not associated with reduced all-cause mortality or cardiovascular morbidity/mortality during the succeeding 13 years.

Wednesday, January 25, 2017

Low Prenatal Weight Gain Does Not Prevent Blood Pressure Issues in "Obese" Women


One idea often promoted by care providers is that keeping prenatal weight gains to the minimum possible or losing weight in pregnancy will prevent blood pressure issues (Gestational Hypertension or Pre-Eclampsia) in "obese" women.

One of the most dreaded complications of pregnancy is blood pressure issues like GHTN and PE, and obese women really are at increased risk for these complications. It is understandable that care providers want to try to prevent that if at all possible.

However, here is a recent study that shows that losing weight and very low gains in pregnancy did not lower the rate of Gestational Hypertention (GHTN) or Pre-Eclampsia (PE) in obese women.

This is important because, as we have discussed before, more and more providers are zeroing in on weight gain in pregnancy as a way to try and prevent complications in higher weight women.

There have been studies which found that lower weight gains were correlated with lower rates of pre-eclampsia, and higher gains with higher rates of pre-eclampsia. However, this doesn't mean that deliberately restricting weight gain prevents PE. As Nohr 2008 states:
Any causal interpretation of the association between total weight gain and these complications is limited. For preeclampsia, high total gain most likely reflects pathologic fluid retention as part of the disease.
In other words, just because very low gain is associated with less pre-eclampsia, it does not follow that making women gain very little weight during pregnancy will prevent pre-eclampsia. Instead, higher weight gain is usually simply a side effect of pre-eclampsia due to the fluid retention and swelling common to pre-eclampsia.

Despite this, many caregivers imply that women can prevent pre-eclampsia by controlling their weight gain during pregnancy. Some are resorting to "scorched earth" tactics, including some truly frightening and extreme nutritional advice, or by encouraging women to lose weight during pregnancy.

This latest study shows that blood pressure issues in pregnancy can't be reliably prevented by having obese women gain minimally or even by losing weight while pregnant. 

Care providers should not be putting higher-weight women on extreme restrictions while pregnant, nor should they be expecting them to lose weight.

Too many care providers see weight gain within recommended limits as a surrogate marker of a woman's nutrition and exercise habits. Women can gain "appropriately" and still have terrible nutrition, and women can gain above or below the recommended limits and still have great nutrition and habits. Discussions about weight gain in pregnancy need to move beyond the scale.

While it's perfectly appropriate to inform higher-weight women of the most optimal prenatal weight gain range to shoot for and to give them reasonable counseling about how to do so, it's much more important to emphasize great nutrition and regular exercise. Then trust the woman's body to gain what it needs to gain for that pregnancy.


Reference

Am J Perinatol. 2014 Dec 8. [Epub ahead of print] The Influence of Gestational Weight Gain on the Development of Gestational Hypertension in Obese Women. Barton JR, Joy SD, Rhea DJ, Sibai AJ, Sibai BM. PMID: 25486285
OBJECTIVE: The objective of this study was to examine the influence of gestational weight gain on the development of gestational hypertension/preeclampsia (GHTN/PE) in women with an obese prepregnancy body mass index (BMI). 
METHODS: Obese women with a singleton pregnancy enrolled at < 20 weeks were studied. Data were classified according to reported gestational weight gain (losing weight, under-gaining, within target, and over-gaining) from the recommended range of 11 to 9.7 kg and by obesity class (class 1 = BMI 30-34.9 kg/m2, class 2 = 35-39.9 kg/m2, class 3 = 40-49.9 kg/m2, and class 4 ≥ 50 kg/m2). Rates of GHTN/PE were compared by weight gain group overall and within obesity class using Pearson chi-square statistics. 
RESULTS: For the 27,898 obese women studied, rates of GHTN/PE increased with increasing class of obesity (15.2% for class 1 and 32.0% for class 4). The incidence of GHTN/PE in obese women was not modified with weight loss or weight gain below recommended levels. Overall for obese women, over-gaining weight was associated with higher rates of GHTN/PE compared with those with a target rate for obesity classes 1 to 3 (each p < 0.001). 
CONCLUSION: Below recommended gestational weight gain did not reduce the risk for GHTN/PE in women with an obese prepregnancy BMI. These data support a gestational weight gain goal ≤ 9.7 kg in obese gravidas.

Friday, January 13, 2017

Common Sense Prenatal Weight Gain Recommendations for "Obese" Women


The 2009 IOM Guidelines for Prenatal Weight Gain
Coming up with official prenatal weight gain guidelines is difficult. There's always a trade-off involved ─ too much weight gain increases the risk for large babies, but too little increases the risk for small babies.

(The effects of weight gain on cesarean rates and pre-eclampsia are harder to figure out because of multiple variables that influence outcomes, so we will limit our discussion for a moment to the influence of weight gain on fetal outcomes.)

This weight gain trade-off has been particularly difficult to figure out in women of size. We tend to have larger babies on average and a very big weight gain seems to increase fetal size particularly strongly in high-BMI women. Nor do we need to gain extra fat reserves for pregnancy and breastfeeding. As a result, the Institute of Medicine (IOM) recommends less weight gain on average for "obese" women (see chart above).

While I don't hate these recommendations, I do have some concerns with them, particularly for women in the borderline categories (see discussion below). Women in these categories may be particularly at risk for poor outcomes, yet they are given the same stringent guidelines (and are often told to gain even less than the guidelines).

I also question how much control women really have over gestational weight gains. Sure, we have control over how much we eat and exercise, but that impact on gain is fairly minimal. There have been many trials of interventions to help obese women keep their weight gains lower; some have had minimal success (about 5 lbs. difference), but many have made little difference in weight gain and do little to improve other outcomes. Even with the best support, many women of size gain above the guidelines ─ not because they are lazy or out of control, but because the guidelines aren't particularly realistic for them.

I am also concerned about harassment and over-intervention in the pregnancies of women who gain above these recommended ranges. I have heard many stories of women of size who are harassed or even punished with early inductions or planned cesareans because they "gained too much."

So while I agree in general with the IOM that obese women don't need to gain as much weight in pregnancy as other women, I do have some reservations about the IOM guidelines and in particular about how they are implemented. But sadly, even these guidelines are not stringent enough for some providers.

Taking The 2009 Guidelines Even Further

Some caregivers believe the 2009 IOM weight gain goals didn't go far enough for obese women. In recent years, unofficial prenatal weight gain advice has gotten progressively more extreme. I call this the "anorexation" of pregnancy weight gain guidelines.

The following are real-life headlines from media articles over the years. Notice how the headlines have changed. They have gone from "obese women should gain LESS weight".....


...to "obese women should gain NO weight"


....to "obese women should LOSE weight" during pregnancy.


Disturbingly, many experts have taken an extremist tone in the media and sold these draconian measures as a public health imperative, which alarms me greatly. Many news articles have pushed this weight restriction agenda, assuring us that very little gain was perfectly safe and even healthier for the plus-sized mother and her baby. Here are just a couple of examples.

One article about the IOM recommendations prominently featured the following quotes promoting even lower gains in high-BMI women:
"I think 11 to 20 pounds is way too much for an obese woman," said Dr. Thomas Myles, a professor of obstetrics and gynecology at Saint Louis University School of Medicine who was not involved in the current recommendations. "I usually tell my [obese] patients that gaining less than 10 pounds and even losing up to 10 pounds is appropriate, whereas for overweight women, gaining 10 to 15 and even up to 20 pounds is appropriate," Myles said. 
Gaining a little less weight than the recommended amount, especially for overweight and obese women, might be better, [Associate Professor, Dr. Emily] Oken [of Harvard University] said.
Another article promoting zero weight gain in obese women featured the following quote from one of its leading investigators in its study's press release (my emphasis):
It may seem counterintuitive to suggest that women control their weight during pregnancy, but these women are already carrying between 50 and 100 extra pounds — and for them any more weight gain could be very dangerous,” said Vic Stevens, PhD, principal investigator who has studied weight loss and weight maintenance for more than 30 years.
Another recent article quoted Dr. Sigal Klipstein, Chair of the American College of Obstetricians and Gynecologists committee on Medical ethics. Even as she discussed the importance of treating obese women humanely during pregnancy, Dr. Klipstein stated:
Although women should not to try to lose weight during pregnancy, “a woman who weighs 300 pounds shouldn’t gain at all,” Klipstein said. “This is not harmful to the fetus.”
But is it really true that very small or non-existent gains are not harmful?

Risks of Too-Small Gains

Those who suggest that gaining little or no weight is optimal for women of size are ignoring all the contrary research.

A significant amount of research has shown that very low weight gains and/or weight loss during pregnancy in women of size carries real risks, including


Tellingly, virtually NO media articles acknowledge that low weight gains have risks or cite the research that shows this. That there are so many articles promoting restricted gain in obese women while completely ignoring the potential harms of such a policy suggests a health agenda that places ideology over evidence.

And now there is even more research suggesting that very low gains may be risky.

A very recent study (Durst 2016) showed that weight gains below the IOM recommendations in obese women led to increased rates of  small-for-gestational-age ("SGA") babies and pre-term births. Another recent study (Cox Bauer 2016) found that gestational weight loss (GWL) was associated with low-birth weight babies. These are a concern because too-small babies are more at risk for future health problems like metabolic syndrome and insulin resistance.

Still another recent study (Hannaford 2016) shows that too-low weight gains, even in obese women, more than doubled the risk for too-small babies. The authors suggested that there may need to be a threshold of a minimum weight gain, even for very high-BMI women, which is a pretty radical suggestion given how many doctors are calling for zero gain or weight loss in this group.

But these new studies are far from the first to find reasons for concern. A brand-new meta-analysis (Xu 2017) of studies on weight gain below the 2009 guidelines in obese mothers found that low weight gain was associated with SGA babies in all obesity categories, not just in the borderline categories.

Yet another meta-analysis (Kapadia 2015) of studies on weight gain in obese pregnant women concluded that, because of its consistent association with too-small babies,
Gestational weight gain below the guidelines cannot be routinely recommended.
Too-small babies and prematurity may not be the only risks of very low weight gains; they may also be implicated in infant deaths.

A recent study (Bodnar 2016) found that weight loss and very low weight gains in Class I and II obese women were associated with a higher risk of infant death.

This is particularly important because research is very clear that SGA babies have a higher risk for stillbirth and neonatal mortality. In addition, some past research (Salihu 2009) shows that SGA babies of obese women are at particular risk for stillbirth.

Sorry, but SGA babies, prematurity, and infant death are pretty significant concerns. People like Dr. Myles, Dr. Oken, Dr. Stevens, and Dr.Klipstein who have been recommending weight gains well below the IOM recommendations have been playing Russian Roulette with the babies of their patients of size.

This is a common problem in medicine ─ taking a recommendation to extreme lengths without adequately studying its safety first.

Obese women as a group may benefit from gaining less weight on average than other women, but it does NOT automatically follow that even less is better

Sadly, while now there are years of data suggesting harms with very low gains and/or gestational weight loss, many experts are STILL telling women of size and their providers that "any weight gain in overweight and obese patients is detrimental to pregnancy outcome." Any weight gain, really?

This bias towards ever-lowered weight gain goals is so ingrained that it continues to deny the existence of any contrary evidence. The 2013 article quoted above advises OB-GYNs:
Weight maintenance and even weight reduction have not proven harmful in obese pregnant patients according to studies in the recent literature
Not proven harmful? This statement completely ignores numerous studies published before 2013 pointing out safety concerns with this advice (Bayerlein 2011, Bodnar 2010, Blomberg 2011, Vesco 2011, Dietz 2006, Potti 2010, Hasegawa 2012).

And now we have EVEN MORE studies showing that there are safety concerns, yet this low/no gain/weight loss advice continues to be given routinely by many providers who assure their patients falsely that there is no reason to worry.

But What About....?

Critics will undoubtedly point out that some of these same studies show benefits of lower gains such as a modestly lower cesarean rate or lower rates of pre-eclampsia. These are valid points. However, that's a whole different discussion because multiple variables influence these complications and it's difficult to tease out a causal relationship.

For example, caregivers are not blinded to their patients' gains. A bigger gain may mean a bigger baby. Fear of a big baby can strongly influence the perception of when a cesarean is "needed" and how many interventions like induction are used. Research shows that women with larger weight gains are induced at higher rates. Therefore it may not be weight gain that's the issue, but rather how the caregiver responds to the gain.

Pre-eclampsia is another situation where you can't jump to conclusions about weight gain. Women with pre-eclampsia typically have a lot of swelling, which means a higher weight gain. As Nohr 2008 states:
Any causal interpretation of the association between total weight gain and these complications is limited. For preeclampsia, high total gain most likely reflects pathologic fluid retention as part of the disease.
In other words, a higher weight gain doesn't necessarily cause pre-eclampsia, but rather it often results from pre-eclampsia. It certainly doesn't mean that a lower weight gain will prevent pre-eclampsia. We just don't know if deliberately restricting weight gain will lower the rate of pre-eclampsia in obese women.

However, it must be acknowledged that too much weight gain is probably also not ideal. Prenatal weight gain clearly influences fetal size, and higher gains seem particularly particularly potent for larger fetal size in high-BMI women. Postpartum, a larger gain may also be difficult to lose; multiple pregnancies with large gains can result in a net overall weight increase that might possibly affect the mother's health. So doctors have to find a balance between the very real risk/benefit trade-offs of too much or too little gain in pregnancy.

That's not easy, and I acknowledge that. But it seems to me that the debate is still very unbalanced, with too many experts still not willing to acknowledge the very real risks of too-small gains.

Deliberately ignoring contrary research is not an evidence-based approach. It smacks of a weight restriction agenda instead of a reasoned approach to best practices.

Summary

For too long, "experts" have been waging a campaign to lower the 2009 IOM guidelines even further for obese women. As a result, many care providers have used draconian pressure on women of size to gain very little or even to lose weight in pregnancy. But there are significant safety concerns with this approach, concerns that these so-called experts are conveniently ignoring.

The research makes several things clear:
  1. Very low weight gain or weight loss is extremely consistent with too-small babies in multiple studies 
  2. Too-small babies are at increased risk for adulthood diseases
  3. Weight loss and very low weight gains may also be associated with a higher risk for infant death and prematurity 
These concerns means it's time for caregivers to STOP promoting extreme weight gain limits and to START acknowledging that very low gains also carry risks. 

Now, it may be that in time, different weight gains will be recommended for different levels of obesity. That seems like a possibility that is worthy of further consideration.

For example, "overweight" women (BMI 25-29) and women with Class I obesity (BMI 30-35) seem to be the most negatively affected by very small weight gains, whereas some research shows that women with Class III obesity (BMI 40-50) and Class IV obesity (BMI 50+) are less affected on average by very low gains.

So there may be some gradations in recommendations in the future, and I welcome discussions about this possibility ─ but given the established risks and the meta-analysis of studies that showed increased SGA risks across all class sizes of obesity, it would still behoove us to be very cautious about recommending very low weight gain even in women with Class III and IV obesity. We simply cannot assume that restricting gains is harmless even there.

Common Sense Recommendations

To me, what's missing from prenatal weight gain recommendations for obese women is nuance. It's time to pull back from prenatal weight gain extremism and show some common sense. Here are the things I think caregivers should take into account when discussing pregnancy weight gain with women of size.

Women of size should be informed in a neutral way of the IOM weight gain recommendations and why they were made. A neutral discussion, with research citations as appropriate, goes a lot further to helping women make informed and empowered decisions. A decision about weight gain goals that comes from the woman herself, rather than being imposed by external forces, is a lot more likely to result in reasonable gains.

How the message is communicated is important. Women should be given reasonable nutritional advice and strongly encouraged to exercise, but risks should not be exaggerated. Lecturing, scare tactics, and condescension means that people will simply tune out recommendations. Treat women as competent partners in their own care and avoid judgment. Emphasize healthy habits rather than numbers on the scale.

Consider tailoring recommendations by BMI. Women in the borderline BMI classes are the most at risk for poor outcomes with very low gains; they should be encouraged to gain nearer to the top of the IOM recommendations. It may even be that women with Class I obesity (BMI 30-35) do best with slightly more gain (15-25 lbs.). Women in Class III (BMI over 40) and Class IV obesity (BMI over 50) can be encouraged to gain towards the lower end of the recommendations or even slightly lower (5-15 lbs.) but great care should be taken that this message does not translate into pressure for restricted intake or extreme measures. Do not assume that very high BMI women have adequate nutritional reserves to make up for a lack of gain; good nutrition is always the priority.

Do not promote actively losing weight in pregnancy. Research shows there are too many potential harms to recommend pursuing gestational weight loss. Some women of size lose without trying; this is not a cause for panic as long as intake is adequate and the baby is growing well. But actively encouraging women to aim for weight loss during pregnancy is different than coincidental weight loss, is likely to result in restrictive behaviors, and probably has far greater risk.

Consider patterns of gestational weight gain. Has the weight gain pattern been relatively smooth? Was there a very large gain in the beginning? At the end? Different patterns may indicate different concerns. Also, don't forget to take pre-conception weight into account; many obese women lose weight in the first trimester and slowly gain that back to a small overall gain. If the initial loss is not counted, it looks like the woman has gained more weight than she actually has. Look at the whole picture.

Do not harass women about weight gain. Weight-related harassment is obnoxious and inappropriate, but it is sadly all too common. Women should not feel afraid to step on the scale at appointments, yet they often experience harassment. Medical assistants should record weight without comment. Care providers can ask neutrally about gains and can work with women on monitoring nutrition and troubleshooting worrisome trends, but judgment and belittling will only backfire. If a woman gains outside of guidelines despite good nutrition and regular exercise, consider other possible variables. Assume that a woman's body will gain what it needs for a healthy pregnancy.

Avoid food extremism. Women of size should not be pressured to strongly restrict calories or to eliminate entire food groups. They should be encouraged to eat reasonable amounts from a wide variety of foods. Nutritional advice should be evidence-based, not from unproven diet trends. Caregivers need to find a way to talk to clients about nutrition and weight gain concerns without condescension or judgment. Work with women and listen to their feedback about their needs.

Individualize care according to the woman's needs. People of size are not all alike. Some fit stereotypical images of fast food consumption and binge eating, others have very healthy habits, and many fall somewhere in between. Ask them respectfully about their habits and concerns; don't make assumptions. Believe what they tell you and advise them accordingly. If habits need improvement, encourage small and reasonable steps and recognize positive achievements.

Remember that weight gains among high-BMI women are highly variable. Research shows that weight gains in pregnancy are less predictable in larger women. Some have very large gains, some have very small gains, and some lose weight without trying. Often the women who gain the most are those who have recently lost weight or who are chronic dieters/weight cyclers, those with lipedema, or those who have swelling with pre-eclampsia. Many factors influence gestational weight gain besides the habits of the women. Acknowledge that some weight gain may be out of their control.

Look more at how the mother and baby are doing than at the scale. Guidelines are more for groups than individuals. While research shows that very high or very low gains are generally best avoided on average, some obese women gain more or less than recommended and have perfectly healthy babies. Some gain a lot and have average-sized babies; some gain almost nothing and have big babies; some lose weight with no obvious harmful effect. Gaining outside the recommendations is not necessarily a cause for alarm, as long as the mother's intake is normal and baby is growing well.

Women should not be subjected to extra interventions if they exceed their providers' weight gain goals. Some fat women are being consciously punished for "too much weight gain" by being subjected to extra interventions like inductions or planned cesareans. However, some of these interventions may occur because of providers' underlying fears about big babies. Care providers must actively examine their own biases so that they do not unconsciously use increased interventions on those who gain more.

Most importantly, focus on nutrition rather than on the scale. Too many providers use weight gain as a marker of pregnancy status and ignore nutrition altogether. What a woman is eating matters more than how much weight she has gained. Women can be given a weight gain goal range, nutritional advice, and exercise opportunities, but nutrition should not be manipulated in order to achieve an arbitrary number. The scale is a poor predictor of outcome and should not be used as a surrogate for nutritional adequacy or fetal status. Focus more on nutrition and concrete signs of how the mother/baby dyad is doing than on numbers on a scale.

Care providers need to bring common sense back into prenatal weight gain guidelines and take a more nuanced approach with women of size.


References

Very Low Gain and Too-Small Infants (Latest Studies)

Am J Perinatol. 2016 Jun 29. [Epub ahead of print] Gestational Weight Gain: Association with Adverse Pregnancy Outcomes. Hannaford KE1, Tuuli MG, Odibo L, Macones GA, Odibo AO. PMID: 27355980 DOI: 10.1055/s-0036-1584583
...OBJECTIVES: We investigated how weight gain outside the IOM's recommendations affects the risks of adverse pregnancy outcomes. STUDY DESIGN: We performed a secondary analysis of a prospective cohort study including singleton, nonanomalous fetuses. The risks of small for gestational age (SGA), macrosomia, preeclampsia, cesarean delivery, gestational diabetes, or preterm birth were calculated for patients who gained weight below or above the IOM's recommendations based on body mass index category....Women who gained weight below recommendations were 2.5 times more likely to deliver SGA and twice as likely to deliver preterm...Obese patients who gained inadequate weight were 2.5 times more likely to deliver SGA. CONCLUSIONS: ...Among obese patients, a minimum weight gain requirement may prevent SGA infants.
Am J Perinatol. 2016 Jul;33(9):849-55. doi: 10.1055/s-0036-1579650. Epub 2016 Mar 9. Impact of Gestational Weight Gain on Perinatal Outcomes in Obese Women. Durst JK, Sutton AL, Cliver SP, Tita AT, Biggio JR. PMID: 2696070
...STUDY DESIGN: A retrospective cohort of perinatal outcomes in obese women who gained below, within, or above the 2009 Institute of Medicine guidelines and delivered ≥ 36 weeks. Additionally, outcomes, according to the rate of GWG (kg/week; minimal [< 0.16], moderate [0.16-0.49], or excessive [> 0.49]) were compared among women delivering preterm. RESULTS: Overall, 5,651 obese women delivered ≥ 36 weeks. GWG above guidelines was associated with increased cesarean section (adjusted odds ratio [aOR]: 1.44, 95% confidence interval [CI]: 1.21-1.72), gestational hypertension (aOR: 1.58, 95% CI: 1.21-2.06), and macrosomia (birth weight ≥ 4,000 g) (aOR: 2.08, 95% CI: 1.62-2.67). GWG below recommendations was associated with less large for gestational age infants (aOR: 0.60, 95% CI: 0.47-0.75)...Minimal weekly GWG was associated with increased spontaneous preterm birth (aOR: 1.56, 95% CI: 1.23-1.98) and more small for gestational age (SGA) infants (aOR: 1.55, 95% CI: 1.19-2.01). Excessive weekly GWG was associated with increased indicated preterm birth (aOR: 1.61, 95% CI: 1.29-2.01), cesarean section (aOR: 1.39, 95% CI: 1.20-1.61), preeclampsia (aOR: 1.83, 95% CI: 1.49-2.26), neonatal intensive care unit admission (aOR: 1.33, 95% CI: 1.08-1.63), and macrosomia (aOR: 2.40, 95% CI: 1.94-2.96).CONCLUSIONS: Obese women with excessive GWG had worse outcomes than women with GWG within recommendations. Limited GWG was associated with increased spontaneous preterm birth and SGA infants.
J Perinatol. 2016 Apr;36(4):278-83. doi: 10.1038/jp.2015.202. Epub 2016 Jan 7. Maternal and neonatal outcomes in obese women who lose weight during pregnancy. Cox Bauer CM, Bernhard KA, Greer DM, Merrill DC. PMID: 26741574
OBJECTIVE: To evaluate neonatal and maternal outcomes in obese pregnant women whose weight gain differed from the Institute of Medicine (IOM) recommendations. STUDY DESIGN: Maternal and neonatal outcomes associated with weight change in pregnancy were retrospectively investigated in women with obesity (body mass index (BMI) ⩾30 kg m(-2); N=10734) who gave birth at 12 hospitals...RESULT: Compared with IOM recommendations, weight loss was associated with twofold greater odds of low birth weight infants and a mean decrease in estimated blood loss of 30 ml; excessive weight gain was associated with doubled odds of gestational hypertension or preeclampsia, fourfold greater odds of macrosomia and a mean decrease in 5-min APGAR of 0.09....
J Matern Fetal Neonatal Med. 2017 Feb;30(3):357-367. Epub 2016 Apr 28. Inadequate weight gain in obese women and the risk of small for gestational age (SGA): a systematic review and meta-analysis. Xu Z, Wen Z, Zhou Y, Li D, Luo Z. PMID: 27033234
...We conducted a meta-analysis of original researches with sufficient information about inadequate GWG in obese women stratified by obesity classes. SGA as the chief outcome was extracted and assessed in our analysis...13 studies (437 512 obese women) were included. Obese women who gained weight below the guidelines had higher risks of SGA than those who gained weight within the guidelines (OR 1.28; 95% CI 1.14-1.43). The same conclusions were also confirmed in Class I, Class II and Class III of obese women: Class I (OR 1.37; 95% CI 1.22-1.54); Class II (OR 1.38; 95% CI 1.24-1.54); Class III (OR 1.25; 95% CI 1.14-1.36). CONCLUSIONS: From our analysis, the guidelines of IOM can be applied to all the classes of obesity. More accurate boundaries for each obesity class should be established to evaluate the maternal and fetal risks. Diverse populations are thus necessary for more studies in the future.
Low Weight Gain/SGA and Risk for Infant Death 

Obesity (Silver Spring). 2016 Feb;24(2):490-8. doi: 10.1002/oby.21335. Epub 2015 Nov 17. Maternal obesity and gestational weight gain are risk factors for infant death. Bodnar LM, Siminerio LL, Himes KP, Hutcheon JA, Lash TL, Parisi SM, Abrams B. PMID: 26572932
OBJECTIVE: Assessment of the joint and independent relationships of gestational weight gain and prepregnancy body mass index (BMI) on risk of infant mortality was performed. METHODS: This study used Pennsylvania linked birth-infant death records (2003-2011) from infants without anomalies born to mothers with prepregnancy BMI categorized as underweight (n = 58,973), normal weight (n = 610,118), overweight (n = 296,630), grade 1 obesity (n = 147,608), grade 2 obesity (n = 71,740), and grade 3 obesity (n = 47,277)...For all BMI groups except for grade 3 obesity, there were U-shaped associations between gestational weight gain and risk of infant death. Weight loss and very low weight gain among women with grades 1 and 2 obesity were associated with high risks of infant mortality....
Am J Perinatol. 2016 Aug 17. [Epub ahead of print] Morbidity and Mortality in Small-for-Gestational-Age Infants: A Secondary Analysis of Nine MFMU Network Studies. Mendez-Figueroa H1, Truong VT2, Pedroza C2, Chauhan SP1. PMID: 27533102
...Data from nine Maternal-Fetal Medicine Units Network studies were used and included nonanomalous singletons at 24 weeks or more and birth weight < 90% for EGA...Among SGA, the likelihood of stillbirth (8.8 vs. 2.5 per 1,000 births; adjusted odds ratio [aOR] 3.98, 95% confidence interval [CI]: 2.92-5.42) and neonatal mortality (14.0 vs. 5.5 per 1,000 births; aOR 3.18, 95% CI: 2.55-3.95) was threefold higher compared with AGA. For the subgroup of newborns of EGA of 32 weeks or more, SGA, compared with AGA, had significantly higher risk of stillbirth (aOR 3.32, 95% CI: 2.16-5.12) and neonatal mortality (aOR 2.50; 95% CI: 1.38-4.54). From 35 weeks onward, the risk of stillbirth among SGA is almost four times higher than for AGA. CONCLUSION: The risk of stillbirth and neonatal mortality is significantly higher with SGA than with AGA. Modification in practice or new management schema may be warranted.
Obstet Gynecol. 2009 Aug;114(2 Pt 1):333-9. Success of programming fetal growth phenotypes among obese women. Salihu HM, Mbah AK, Alio AP, Kornosky JL, Bruder K, Belogolovkin V. PMID: 19622995
...METHODS: This was a retrospective cohort study using the Missouri maternally linked cohort files (years 1978-1997)...Fetal growth phenotypes were defined as large for gestational age (LGA), appropriate for gestational age (AGA), and small for gestational age (SGA)...Neonatal mortality among LGA infants was similar for obese...and normal...weight mothers (OR 1.05, 95% confidence interval [CI] 0.75-1.48) and regardless of obesity subtype. By contrast, SGA and AGA infants programmed by obese mothers experienced greater neonatal mortality as compared with those born to normal weight mothers (AGA OR 1.45, 95% CI 1.32-1.59; SGA OR 1.72, 95% CI 1.49-1.98). CONCLUSION: Compared with normal weight mothers, obese women are least successful at programming SGA, less successful at programming AGA, and equally as successful at programming LGA infants.
Low Weight Gain and Risk for Prematurity

Obesity (Silver Spring). 2013 Dec;21(12):E770-4. doi: 10.1002/oby.20490. Epub 2013 Jul 5. Gestational weight loss and perinatal outcomes in overweight and obese women subsequent to diagnosis of gestational diabetes mellitus. Yee LM, Cheng YW, Inturrisi M, Caughey AB. PMID: 23613187
...Retrospective cohort study of 26,205 overweight and obese gestational diabetic women enrolled in the California Diabetes and Pregnancy Program. Women with GWL [Gestational Weight Loss] during program enrollment were compared to those with weight gain...RESULTS: About 5.2% of women experienced GWL. GWL was associated with decreased odds of macrosomia (aOR 0.63, 95% CI 0.52-0.77), NICU admission (aOR 0.51, 95% CI 0.27-0.95), and cesarean delivery (aOR 0.81, 95% CI 0.68-0.97). Odds of SGA status (aOR 1.69, 95% CI 1.32-2.17) and preterm delivery <34 weeks (aOR 1.71, 95% CI 1.23-2.37) were increased. CONCLUSIONS: In overweight and obese women with GDM, third trimester weight loss is associated with some improved maternal and neonatal outcomes, although this effect is lessened by increased odds of SGA status and preterm delivery. Further research on weight loss and interventions to improve adherence to weight guidelines in this population is recommended.
BJOG. 2011 Jan;118(1):55-61. doi: 10.1111/j.1471-0528.2010.02761.x. Epub 2010 Nov 4. Associations of gestational weight loss with birth-related outcome: a retrospective cohort study. Beyerlein A, Schiessl B, Lack N, von Kries R. PMID: 21054761
...DESIGN: Retrospective cohort study. SETTING AND POPULATION: Data on 709 575 singleton deliveries in Bavarian obstetric units from 2000-2007 were extracted from a standard dataset for which data are regularly collected for the national benchmarking of obstetric units...RESULTS: GWL was associated with a decreased risk of pregnancy complications, such as pre-eclampsia and nonelective caesarean section, in overweight and obese women [e.g. OR = 0.65 (95% confidence interval: 0.51, 0.83) for nonelective caesarean section in obese class I women]. The risks of preterm delivery and SGA births, by contrast, were significantly higher in overweight and obese class I/II mothers [e.g. OR = 1.68 (95% confidence interval: 1.37, 2.06) for SGA in obese class I women]. In obese class III women, no significantly increased risks of poor outcomes for infants were observed. CONCLUSIONS: The association of GWL with a decreased risk of pregnancy complications appears to be outweighed by increased risks of prematurity and SGA in all but obese class III mothers.
Epidemiology. 2006 Mar;17(2):170-7. Combined effects of prepregnancy body mass index and weight gain during pregnancy on the risk of preterm delivery. Dietz PM, Callaghan WM, Cogswell ME, Morrow B, Ferre C, Schieve LA. PMID: 16477257
...METHODS: Using data from the Pregnancy Risk Assessment Monitoring System in 21 states, we estimated the risk of very (20-31 weeks) and moderately (32-36 weeks) preterm delivery associated with a combination of prepregnancy body mass index (BMI) and gestational weight gain among 113,019 women who delivered a singleton infant during 1996-2001...RESULTS: There was a strong association between very low weight gain and very preterm delivery that varied by prepregnancy BMI, with the strongest association among underweight women (adjusted odds ratio = 9.8; 95% confidence interval = 7.0-13.8) and the weakest among very obese women (2.3; 1.8-3.1)...Women with very high weight gain had approximately twice the odds of very preterm delivery, regardless of prepregnancy BMI. CONCLUSIONS: This study supports concerns about very low weight gain during pregnancy, even among overweight and obese women, and also suggests that high weight gain, regardless of prepregnancy BMI, deserves further investigation.
J Matern Fetal Neonatal Med. 2012 Oct;25(10):1909-12. doi: 10.3109/14767058.2012.664666. Epub 2012 Mar 12. Gestational weight loss has adverse effects on placental development. Hasegawa J1, Nakamura M, Hamada S, Okuyama A, Matsuoka R, Ichizuka K, Sekizawa A, Okai T. PMID: 22348351
OBJECTIVE: To clarify whether mothers with gestational weight loss (GWL) were likely to have adverse effects on the placenta. STUDY DESIGN: Subjects who delivered viable singleton infants after 24 weeks of gestation were enrolled. A retrospective analysis to evaluate cases of GWL in association with the findings of the placenta and amniotic membrane after delivery was conducted. After consideration of confounders, a case-control study with matched pairs (1:2) was performed. RESULTS: Of all subjects (5551 cases), 83 cases (1.5%) with GWL were found. Since the pre-pregnancy maternal body mass index (BMI) was significantly higher in cases, 166 controls with a matched BMI were selected. The neonatal birth weights, placental weights and the umbilical cord length in cases were significantly smaller than in controls (p < 0.05). Preterm delivery and small for gestational age (SGA) infants were more frequently observed in cases compared with controls [odds ratio (OR) 6.3; 95% confidence interval (CI) 3.3, 12.1, OR 4.3; 95% CI 1.9, 9.9]. pPROM were observed in 10.8% of the cases and 1.8% of the control (OR 6.6; 95% CI 1.7, 25.1). However, the frequencies of chorioamnionitis and the cervical length at second trimester were not different between the two groups. CONCLUSION: GWL is associated with SGA, small placenta, short umbilical cord length, preterm delivery and pPROM.