Friday, July 18, 2014

Birth Control And Obesity

sharma-obesity-birth-control-pillAlthough obesity is a well-recognised factor for female infertility, the vast majority of women with excess weight are probably more interested in effective birth control.

That this is not as simple as it seems is evident from an article by Sheila Mody and Michelle Han from the University of California, San Diego, published in Clinical Obstetrics and Gynecaology.

The paper succinctly reviews a wide range of issues related to birth control and obesity.

To begin with, the authors points out that unintended pregnancies in obese women are often a problem simply because obese women are far less likely to use effective contraception than non-obese women. This non-use may in part be attributable to fear of weight gain, when most studies show that modern hormonal contraception is associated with almost no weight gain. The exception appears to be depot-medroxyprogesterone (DMPA), which may cause about 5 lb weight gain in the first year of use.

As for efficacy, the data show that unintended pregnancy rates among overweight women using oral contraceptives are similar or slightly higher than that among nonoverweight women. The reasons for these higher rates are not exactly clear.

Fortunately, the efficacy of intrauterine devices (IUD) appear no different between obese and non-obese women although the insertion of an IUD maybe more difficult in obese women because of poor visualization of the cervix and limited assessment of uterine position (a problem that can often be solved with the help of an ultrasound).

The paper also discusses the suitability of the vaginal vaginal contraceptive ring, which has been hypothesized to offer higher hormone levels for obese women than oral contraceptives because the hormones are absorbed directly into the vaginal mucosa and do not go through the first- pass liver metabolism.

Finally, the paper discusses issues around contraception for women who have undergone bariatric surgery (who have a particularly high rate of unintended pregnancies) as well as best practices for emergency contraception.

This is clearly information that all clinicians who counsel obese women should be aware of.

@DrSharma
Edmonton, AB

ResearchBlogging.orgMody SK, & Han M (2014). Obesity and Contraception. Clinical obstetrics and gynecology PMID: 25029338

 

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Wednesday, June 18, 2014

4th Canadian Obesity student Meeting (COSM 2014)

Uwaterloo_sealOver the next three days, I will be in Waterloo, Ontario, attending the 4th biennial Canadian Obesity Student Meeting (COSM 2014), a rather unique capacity building event organised by the Canadian Obesity Network’s Students and New Professionals (CON-SNP).

CON-SNP consist of an extensive network within CON, comprising of over 1000 trainees organised in about 30 chapters at universities and colleges across Canada.

Students and trainees in this network come from a wide range of backgrounds and span faculties and research interests as diverse as molecular genetics and public health, kinesiology and bariatric surgery, education and marketing, or energy metabolism and ingestive behaviour.

Over the past eight years, since the 1st COSM was hosted by laval university in Quebec, these meetings have been attended by over 600 students, most presenting their original research work, often for the first time to an audience of peers.

Indeed, it is the peer-led nature of this meeting that makes it so unique. COSM is entirely organised by CON-SNP – the students select the site, book the venues, review the abstracts, design the program, chair the sessions, and lead the discussions.

Although a few senior faculty are invited, they are largely observers, at best participating in discussions and giving the odd plenary lecture. But 85% of the program is delivered by the trainees themselves.

Apart from the sheer pleasure of sharing in the excitement of the participants, it has been particularly rewarding to follow the careers of many of the trainees who attended the first COSMs – many now themselves hold faculty positions and have trainees of their own.

As my readers are well aware, I regularly attend professional meetings around the world – none match the excitement and intensity of COSM.

I look forward to another succesful meeting as we continue to build the next generation of Canadian obesity researchers, health professionals and policy makers.

You can follow live tweets from this meeting at #COSM2014

@DrSharma
Waterloo, Ontario

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Tuesday, June 17, 2014

US Obstetricians and Gynecologists Weight In On Ethical Obesity Care

ACOG_Logo.svg_This month the the Committee on Ethics of the American College of Obstetricians and Gynecologists released a position statement on obesity that advices its fellows to be prepared to meet the challenges of women with obesity with compassion and without bias.

The statement offers the following recommendations and conclusions:

  • Physicians should be prepared to care for obese patients in a nonjudgmental manner, being cognizant of the medical, social, and ethical implications of obesity.
  • Recommendations for weight loss should be based on medical considerations.
  • An understanding that weight loss entails more than simply counseling a woman to eat less and exercise more and a willingness to learn about the particular causes of a patient’s obesity will assist physicians and other health care professionals working with them in providing effective care.
  • Physicians can serve as advocates within their clinical settings for the necessary resources to provide the best possible care to obese women.
  • It is unethical for physicians to refuse to accept a patient or decline to continue care that is within their scope of practice solely because the patient is obese. However, if physicians lack the resources necessary for the safe and effective care of the obese patient, consultation or referral or both are appropriate.
  • Physicians should work to avoid bias in counseling regardless of their own body mass index status.
  • Obesity education that focuses on the specific medical, cultural, and social issues of the obese woman should be incorporated into physician education at all levels.

The entire statement is available here.

It would certainly be nice to see similar statements from other professional bodies (e.g. orthopedic surgeons).

Hopefully, these recommendations will soon be reflected in clinical practice.

@DrSharma
Edmonton, Alberta

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Thursday, February 13, 2014

Guest Post: Everything You Must Know About Pregnancy and Weight Gain

Zach Ferraro, PhD, University of Ottawa

Zach Ferraro, PhD, University of Ottawa

Today’s post is from Zach Ferraro, PhD, a former CON-SNP National Executive member (2008-12), CON Boot Camper (2008) and Inaugural recipient of CON Rising Star Award (2012). Currently, Zach is a clinical research associate in the Division of Maternal-Fetal Medicine at the Ottawa General Hospital and PT Professor in Human Kinetics at the University of Ottawa. He is also a member of the CON 5 As for pregnancy working group.

Regular readers of these pages will recall that the intrauterine environment plays a vital role in healthy neonatal development and is directly influenced by maternal nutrition, physical activity, xenobiotics and pregnancy weight gain. This interaction is commonly referred to as ‘fetal programming’ or more appropriately termed fetal plasticity. That is, the ability of the developing fetus to grow and respond to external stimuli whether intrauterine or environmental. Thus, all prenatal exposures, positive and negative, have the potential to affect the short- and long-term health of the child.

It is now well-established that excess gestational weight gain (GWG) is an independent predictor of large for gestational age (LGA) neonates and postpartum weight retention (PPWR) in the mother. Simply, moms who gain greater than the recommended amount of weight, according to their pre-pregnancy BMI, subsequently carry this excess weight forward into the next pregnancy causing a rightward shift in their BMI after delivery. In addition, babies born large (LGA) tend to track their excess weight throughout life and are at greater risk of becoming obese as adults. Although the mechanisms explaining these associations are far from unraveled, both LGA and PPWR exacerbate what is referred to as the intergenerational cycle of obesity.

So what can care providers do to help minimize the ill-effects of excessive GWG? Several lifestyle interventions during pregnancy are reported in the literature and have yielded mixed results. This is largely due to heterogeneity in intervention type (diet or physical activity or psychological support or all the above) and intensity (intensive clinical intervention vs. hands off approach). We, in addition to others, have also reported that knowledge transfer between patients and providers may be partially responsible for the limited treatment effects seen in some interventions. Nonetheless, in the absence of any between group differences in GWG guideline adherence and maternal-fetal outcomes between lifestyle intervention and standard care, it is important to remember that healthy living behaviours were not harmful and may have resulted in increased fitness and/or alterations in body composition (which is rarely if at all ever measured). Thus, healthy living trumps numbers on the scale, something readers of these pages are all too familiar with.

Given the many known benefits of appropriate GWG how can we help providers implement, and patients adhere to, recommendations and in turn improve maternal-fetal outcomes? In the fall of 2013 the Institute of Medicine (IOM) chaired a workshop entitled “Leveraging Action to Support Dissemination of Pregnancy Weight Gain Guidelines” to help address this important clinical issue. A link to the 97 page report can be found at the end of the post. During the workshop the IOM heard from clinical experts, scientists, researchers and public health advocates on topics ranging from communicating the pregnancy weight gain guidelines, how to support behaviour change, implementing the guidelines, an overview of the importance of the first 1000 days and collaborating to increase messaging and uptake of the guidelines. Following the workshop it was concluded that strong and consistent messaging was required to assist with patient-provider uptake. Additionally, several resources including physical activity and GWG prescription pads were shared as examples of tools care providers could use with patients. A conceptual model, GWG poster, an easy-to-read information pamphlet, GWG tracker, 5 common myths heard from expectant mothers, and an interactive online tool were also highlighted.

To conclude the IOM committee recommended adopting a ‘before, between and beyond’ approach to connect pregnancy care with general health care to take advantage of the adage ‘prevention before conception’. Changing the structure of prenatal care was suggested to encourage visits earlier in pregnancy as a way that reflects each woman’s unique situation and risk profile; noting that the reversal of early excessive GWG is challenging at best. Lastly, recommendations to motivate women to adopt healthy behaviours by initiating a dialogue between patient and provider were suggested to leverage action across the continuum of prenatal care. It is important to note that many of these recommendations are included within the soon to be released CON 5 As for Healthy Pregnancy Weight Gain.

As the GWG research continues to mount and novel prenatal interventions using sophisticated technology attempt to facilitate behaviour change, care providers and patients require immediate tools/strategies to help improve maternal-fetal outcomes. In addition to the CON 5 As for Pregnancy, providers can be confident recommending routine physical activity (in those without contraindications), nutritional guidance and caloric literacy given that the caloric requirements of pregnancy are modest (~300 kcal/day in term 2 and 3), encouraging a food diary and physical activity log and tracking GWG on their own using the tools provided within the report. Collectively, patients and providers can work together with open dialogue to ensure optimal health and wellness for mom and baby.

You can follow Dr. Zach Ferraro on twitter @DrFerraro for frequent discussion on the topic. More details can be found at www.DrFerraro.ca

References:

Institute of Medicine (2013). Leveraging Action to Support Dissemination of Pregnancy Weight Gain Guidelines

Ferraro ZM, Boehm K, L Gaudet, KB Adamo. Counseling about gestational weight gain and healthy lifestyle during pregnancy: Canadian maternity care providers’ self-evaluation. International Journal of Women’s Health. 2013:5 629-636. 

Ferraro ZM, N. Barrowman D. Prud’homme, MW. Walker, M. Rodger, SW. Wen, KB. Adamo. Excessive gestational weight gain predicts large for gestational age neonates independent of maternal body mass index. Journal of Maternal-Fetal & Neonatal Medicine. 2012;25(5):538-542.

Institute of Medicine (2009). Weight Gain During Pregnancy: Reexamining the Guidelines

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Friday, February 7, 2014

No Easy Path To Dropping Pounds After Pregnancy

sharma-obesity-pregnancy5Gaining excessive weight during pregnancy and retaining much of it after delivery is ones of the most common drivers of adult obesity in women.

Emerging evidence supports the notion that both may well be detrimental to the health of mothers (and their kids).

Unfortunately, it appears that behavioural intervention during pregnancy to reduce long-term weight retention is a lot more challenging that one may expect.

This is the rather disappointing outcome of a randomised controlled trial by Suzanne Phelan and colleagues, published in the American Journal of Clinical Nutrition.

The trial included 400 US Women, half of who were overweight or obese, randomly assigned to a behavioural intervention or control group beginning around the 13th week into their pregnancy.

The intervention (Fit for Delivery) consisted of one face-to-face visit with an interventionist at the onset of treatment, the provision of body-weight scales, food records, and pedometers to promote adherence to daily self-monitoring, weekly postcards prompting healthy eating and exercise habits, personalized graphs of their weight gain with feedback, and supportive phone calls from the dietitian during the intervention. This intervention continued till delivery.

Four out of five of the participants completed the 12-mo assessment.

Overall the intervention did not increase the participants’ chances of achieving their prepregnancy weights. Even the completer analysis showed non-significant trends at best – this despite women in the intervention group reporting higher levels of dietary restraint and more frequent self-monitoring of body weight.

Thus, this level if intervention, which far exceeds usual care during pregnancy for most women, does not appear to effectively reduce post-pregnancy weight retention.

Incidentally, the only predictors of excessive weight retention were pre-pregnancy BMI and excessive gestational weight gain. Breastfeeding, age, parity, and delivery weeks were not.

Thus, although excessive pregnancy weight gain and post-pregnancy weight retention are common problems with significant negative health impacts on both mother and child, it will apparently take far more than an additional visit with a dietitian and exercise counsellor or postcards and telephone reminders to impact body weight.

I wonder if anyone else is not all too surprised by these findings?

@DrSharma
Edmonton, AB

ResearchBlogging.orgPhelan S, Phipps MG, Abrams B, Darroch F, Grantham K, Schaffner A, & Wing RR (2014). Does behavioral intervention in pregnancy reduce postpartum weight retention? Twelve-month outcomes of the Fit for Delivery randomized trial. The American journal of clinical nutrition, 99 (2), 302-11 PMID: 24284438

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In The News

Diabetics in most need of bariatric surgery, university study finds

Oct. 18, 2013 – Ottawa Citizen: "Encouraging more men to consider bariatric surgery is also important, since it's the best treatment and can stop diabetic patients from needing insulin, said Dr. Arya Sharma, chair in obesity research and management at the University of Alberta." Read article

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