New Guidelines Address Obesity Before and During Pregnancy

As blogged before, both prepregnancy overweight and excessive weight gain during pregnancy can have significant health impacts on mother and child. As many readers of these pages may know, there is also an accumulating body of evidence suggesting that intrauterine and early post-partum epigenetic programming may play an important role in promoting and perpetuating the current epidemic of childhood obesity. It is therefore of interest that this week, the American Dietetic Association and the American Society for Nutrition released new guidelines on addressing excess weight before and during pregnancy. While there is nothing really novel in the advise given to prospective mothers, the fact that prevention and management of excess weight before and during pregnancy now deserves its own guidelines, is clearly a sign of the increasing recognition of this important issue. Clearly, the widespread notion of “eating for two” is more than obsolete! AMS Edmonton, Alberta

Pregnancy and Fertility after Bariatric Surgery

Today I am presenting a talk on obesity at the 54th Annual Meeting of the Canadian Fertility and Andrology Society, being held in Calgary, Alberta. The reason that I’ve been invited, is because, as many of you know, excess weight has a significant negative effect on fertility rates. Indeed, obesity may today be by far the most frequent cause of failure to conceive. While my talk is on the general approach to obesity diagnosis and management, it is timely that in this week’s issue of JAMA, Melinda Maggard et al. from the University of California, Los Angeles, CA, publish a systematic review on pregnancy and fertility following bariatric surgery. For their review, Maggard and colleagues searched the Nationwide Inpatient Sample (1998-2005) and multiple electronic databases to identify articles published between 1985 and February 2008 on bariatric surgery among women of reproductive age. Of 260 screened articles, 75 were included. Women aged 18 to 45 years accounted for 49% of all patients undergoing bariatric surgery (>50,000 cases annually for the 3 most recent years). Matched cohort studies showed lower maternal complication rates after bariatric surgery than in obese women without bariatric surgery, or rates approaching those of nonobese controls. Rates of gestational diabetes (0% vs 22.1%, P < .05) and preeclampsia (0% vs 3.1%, P < .05) were lower in the bariatric surgery patients. These findings were supported by 13 other bariatric cohort studies. Neonatal outcomes were similar or better after surgery compared with obese women without laparoscopic adjustable gastric band surgery (7.7% vs 7.1% for premature delivery; 7.7% vs 10.6% for low birth weight, P < .05; 7.7% vs 14.6% for macrosomia, P < .05). Unfortunately, studies regarding nutrition, fertility, cesarean delivery, and contraception were limited. For e.g. on the issue of fertility, the authors identified 6 studies generally showing improved fertility, although due to lack of a denominator (the number of women actually trying to get pregnant), the impact of surgery is hard to determine. Nevertheless, data clearly shows improvements to complete disappearance of polycystic syndrome and normalization of hormonal patterns and return of normal menstrual cycles. On the issue of contraception there are isolated reports of failure of contraception following bypass surgery – systematic or controlled trial are lacking. In summary, the authors concluded that the rates of many adverse maternal and neonatal outcomes may be lower in women who become pregnant after having had bariatric surgery compared… Read More »

Time to Limit Weight Gain in Pregnancy?

Regular readers of my blog will have noticed several previous postings on the issue of maternal obesity and health risk for mother and infant. This issue seems to be developing into a really “hot topic”, at least judging from the flurry of articles in the most recent alerts from CON/McMaster University’s OBESITY+ services. The first was a nested case-control study comparing 251 mothers who developed gestational diabetes to matched normal controls, both selected from a multiethnic cohort of 14,235 women. In this study, Monique Heddersen and colleagues from Kaiser Permanente, Oakland, CA, demonstrated that women who gained significant amount of weight in the five years preceding their pregnancy, had a 2.5-fold higher risk of GDM compared to women with stable weight. Gestational diabetes has been linked to increased birth weights and later risk of obesity in the offspring (American Journal of Obstetrics and Gynecology, April 2008). In the same issue of AJOG, Holly Hull from Columbia University, New York, NY, compared body weight and composition (air-displacement plethysmography) in 33 neonates born to mothers with a normal pregravid BMI to 39 neonates born to overweight/obese mothers with normal glucose tolerance. Babies born to normal BMI mothers had significantly less total and relative fat and more fat-free mass than babies born to overweight/obese mothers. Although preliminary, the authors interpret these data to suggest (and I agree) that the antecedents of future disease risk (eg, cardiovascular disease, diabetes, and obesity) occur early in life. So what, if anything, can we do about this? That question was addressed by Wolff and colleagues from the University of Copenhagen, who performed a randomized controlled trial in 50 obese mothers (pre-pregnancy BMI around 35) with or without restriction of gestational weight gain to 6-7 kg by ten 1-h dietary consultations. Not only did the women in the intervention group successfully limit their energy intake to restrict gestational weight gain to 6.6 kg (vs. a gain of 13.3 kg in the control group) but this was associated with a significantly reduced fasting glucose and insulin levels in the intervention group with no apparent harm to the babies. Thus, restriction of gestational weight gain in obese women is achievable and reduces the deterioration in the glucose metabolism. (International Journal of Obesity, March 2008) Together these studies clearly support the importance of addressing obesity in mothers before and during pregnancy – an intervention that will hopefully prove beneficial to both… Read More »

Supersizing Pregnancy Care: the Dawn of Bariatric Obstetrics?

Last week’s issue of the New England Journal of Medicine features an article by Susan Chu and colleagues from the US Centers for Disease Control and Prevention (Atlanta, GA) on the impact of obesity on health care during pregnancy. Dr. Chu and colleagues examined 13,442 pregnancies (2000-2004) according to pre-pregnancy BMI. After appropriate corrections for confounders, hospital stay for delivery was significantly greater by approximately a full day among women with obesity than in normal weight women. Most of the increase in length of stay associated with higher BMI was related to increased rates of cesarean delivery and obesity-related high-risk conditions. A higher-than-normal BMI was also associated with significantly more prenatal fetal tests, obstetrical ultrasonographic examinations, dispensed medications, telephone calls to obstetrics, and prenatal visits with physicians. Thus clearly, obesity during pregnancy is associated with increased use of health care services. Obesity in pregnancy is not a topic that is discussed much in the media. I first became aware of the magnitude of this problem, when I was approached by the obstetrics folks from the McMaster University Hospital (Hamilton, Ontario) who found themselves looking after an increasing number of severely obese expecting mothers. This contact led to the initiation of a working group on bariatric nursing that devised protocols for looking after large and very large mothers. I further realised the importance of this issue when I heard about the apparently close link between maternal obesity and the risk for both the mother and infant and the fact that obesity during pregnancy may set up the infant for future obesity through epigenetic programming. As I have blogged before, limiting weight gain during pregnancy in overweight and obese mothers may be a first step towards preventing childhood obesity. Given that there are around 13,000 babies born in the Capital Health Region every year, about 10% of these to mothers with pre-pregnancy BMI>30, the finding of Dr. Chu et al., if translated to our region, could mean as many as 1,500 or so extra days in hospital for new mothers, much of this due to obesity-related risk. Obviously more screening tests, more frequent prenatal visits and more medications would add to the costs. Clearly, the issue of increasing weights and weight gain in women of child-bearing age is a public health issue whose consequences and impact have yet to be fully appreciated. As these issues affect both mothers and infants, it would… Read More »

The Difference Between “Ozempic-Face” and “Mounjaro-Babies”

Followers of social and other media will have by now heard the term “Ozempic-” or “Wegovy-face”, which refers to the facial changes associated with the use of the anti-obesity medication semaglutide. These facial changes have been said to deepen facial folds, increase wrinkles, and often make people look older and, in extreme cases, rather unhealthy.  Nothing about this is in anyway directly attributable to the specific action of semaglutide. In fact, these are the very facial changes that we routinely see in anyone losing a significant amount of weight, irrespective of the reason.  Thus, we could call this “Keto-face”, “Atkin’s-face”, “Formula-diet-face”, “Gastric-Bypass-face”, or even “Marathon-face”, if that’s the reason you went and lost a significant amount of weight, respectively.  Thus, “Ozempic-face” has nothing to do with any particular  biological action of semaglutide that specifically affects facial body fat depots but, rather, is simple the natural consequence of weight loss.  This, however, is not entirely the case for “Mounjaro-babies”, a term that has been used for the occasional unplanned pregnancy in patients taking the GLP-1/GIP dual agonist tirzepatide or Mounjaro.  Part of this is of course related to the fact that weight-loss (by any means) will increase fertility in women of child-bearing age. Thus,anyone working in bariatric medicine has probably seen “keto-babies”, “formula-diet babies”, and “bariatric-surgery babies” (and of course “Ozempic” and “Wegovy babies”), all attributable to the impact of weight-loss on fertility.  However, this is only part of the story. It should be well-known by now that GLP-1 analogues can directly affect gastro-intestinal motility, often resulting in delayed gastric emptying, and in some cases, vomiting or even diarrhoea, especially during the early phase of treatment. This can markedly change the effectiveness of oral contraception – leading to unplanned pregnancies.  Thus, pregnancies in patients on a GLP-1 or a GLP-1/GIP analogue can be due to the rather unspecific effect of weight loss on fertility, but also due to the medication-specfiic effects on gastro-intestinal motility and emesis. This is something all women of chid-bearing aged should be warned of when using GLP-1 or GLP-1/GIP analogues.  For e.g. the FDA-mandated label for Mounjaro clearly states for women of reproductive potential, “Advise females using oral contraceptives to switch to a non-oral contraceptive method, or add a barrier method of contraception for four weeks after initiation and for four weeks after each dose escalation.” As for women, who get pregnant whilst on Mounjaro, the FDA… Read More »