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Sunday
May282006

Why Do So Many Fat Women Struggle With Breastfeeding...

... yet some, like myself, don't?

I've written before about how when I started doing birth work 2 decades ago I rarely saw posterior babies and then about 1997 or so, there was an explosion of babies being born by cesarean because they were persistantly posterior. Those numbers have only increased. It took awhile to figure out what the deal was and many of us attribute it to two things: recliners and SUVs. Positions that put the mom leaning backwards encourages the baby into the posterior position. When we actively help women to remain leaning forward (hips lower than the pelvis, for example), we see far, far fewer posterior babies, long, drawn out labors, and cesareans.

Similar changes have happened with breastfeeding.

Over all these years, I have watched as more and more women are unable to nurse their babies because of inadequate milk supplies. What is going on? One theory being watched and studied is that our ever-more-fat culture is contributing to lactogenesis II (failure to get breastfeeding established due to low or non-existent milk supply). I am at a breastfeeding conference and keep hearing more and more about PCOS, diabetes (I and II), insulin resistance and obesity being attributed to lactogenesis. I first heard about this at this same conference 2 years ago and knew I was on the right track believing there was a connection, but hadn't heard anyone else talking about it until then. Once I had that validation and studies started coming out, the connection seemed obvious.

I have very little actual experience with this, but have been asking CNMs and midwives around the country about their take on all of this. I want to know what they are doing - what meds are working - how to better help a woman who very well might be on the failure side of the equation. (The stats I have seen [I'll put the citations up when I find them at home] are it is about 50/50 success/failure rate for seriously obese moms and women who have been diagnosed with PCOS.)

It seems that Metformin (Glucophage) is the medication of choice. Clomid used to be a first line of defense for infertile women until they realized that PCOS and obesity would be dramatically helped by Metformin. Now, most women beginning infertility work-ups, if anywhere near overweight, are put on Metformin as a regulating and initial step towards conceiving. So, instead of prescribing Reglan and Domperidone as first lines of defense, perhaps Metformin should be on the prescription pad.

I have heard great things about Metformin and milk supply increases. It takes time, sometimes a couple of months, but it usually helps if there are no other organic issues going on.

I have a client right now (she reads and knows I am writing about her), quite obese with her second bout of Lactogenesis. The first time, even with help from the LC, milk production was minimal and mom supplemented using an SNS. This time, armed with reams of information, she ordered Domperidone from out of the country, got the pump primed, had the LC at the ready, hired me as a monitrice and had a beautiful birth where no separation from the mother or baby occurred.

Separate from these issues was postpartum pre-eclampsia (a whole post on its own) and re-hospitalization for a couple of days on magnesium sulphate and one dose of an anti-seizure medication - this happening after both pregnancies (far, far worse after the first child).

So, did the PP Pre-eclampsia cause the Lactogenesis? Or the obesity (and probable PCOS)?

Most research would say the PP Pre-eclampsia didn't help, but the obesity seems to be the actual culprit.

So, after running through the new well-thought out plan she had, she still remains milk deficient. She talked her doctor into prescribing Metformin and initially began 500 mg in the morning and 500 mg at night. Mom emailed me after a week on the meds and was very frustrated and disappointed that it hadn't worked... she was nearly resigned to the fact that she would have to use the SNS as she had with her first. I explained that 1000 mg is a loading dose and that 1500 - 2000 mg seems to be a much better level to have success at. Mind you, I am NOT a doctor, nor can I prescribe meds. These are just my anecdotal and personal experiences I am speaking of. She made the decision to increase her dosage to 1500 mg per day and I also explained that it can take a couple of months - not weeks - to see a change in the milk supply.

Metformin is notorious for causing intestinal disturbances such as diarrhea and gas along with stomach aches. I nearly quit taking it because of the stomach ache I lived with for several months. Once I got past that phase, I began to see a difference in my own blood glucoses and have heard women say similar stories about their own glucoses. Midwives I have spoken with say the threshhold of diarrhea to normal stool seems to be when milk supply increases - if it is going to increase at all. Letting women know there is a period of adjustment for this medication is crucial for compliance and appropriate expectations.

So, in the face of growing research about obesity/fat and lactation failure, could this be one way to get women to comply with proper diets and taking their Metformin? That if they don't, they have a 50/50 chance of an unsuccessful breastfeeding attempt (and the misery that goes along with that)? I don't know if it would have been incentive enough for me to get to a "normal" weight before having kids or to try and diet/change my eating habits postpartum; I am too much of a food addict, lazy, and had zero time to do much of anything but be a mommy all those years ago. I was also in the lucky half that successfully breastfed (several kids, sometimes all at the same time!), so it's hard for to know what my response would have been if I hadn't have been able to nurse that first time.

Would I have cared enough to try? Would I have had enough motivation to explore options as my client has? Would I have used an SNS for a year as my client did and is doing? Would I nurse my child even if no milk were coming out - as my client has done with her first child?

Knowing myself, I don't think so. I don't like saying that, either. I admire my client so much for all she does for her children. Much of the time at her own health's expense. I try to be encouraging and loving and let her know what a phenomenal job she is doing despite the plethora of obstacles she has had thrown in her face (and at her breasts!). I admire her tenacity. I know I wouldn't have had an iota of what she has inside that heart and mind of hers.

I'll let you know how the Metformin works in a couple of months.

Some sites regarding these issues:

Obesity and Lactogenesis II

http://jn.nutrition.org/cgi/content/full/131/11/3009S

A slew of articles found here on Pub Med

http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?CMD=search&DB=pubmed

Diminished prolactin and milk production failure

http://pediatrics.aappublications.org/cgi/content/abstract/113/5/e465

A great article about Metformin to increase milk production - Lisa Marasco is quoted throughout; she is the woman I heard speak 2 years ago about this very issue - naming the hunch I'd already had (along with many others, apparently!)

http://breastfeed.com/resources/articles/pcos.htm

References (6)

References allow you to track sources for this article, as well as articles that were written in response to this article.
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Reader Comments (11)

Have been reading your blog for awhile but have been compelled out of lurking for this post :) This information is very interesting to me as I am sure I had low supply and have only read 1 reference to obesity and supply on kellymom, it seems to be something not often spoke about.

I fed on demand, and I have never leaked, rarely felt any fullness, can't express to save my life, and my DD put on signifigantly more weight once she started solids at 6 months old. For someone who is generally pretty hormonally "right" this baffled me a bit, that I seem like such a low responder to all that demand! (she fed a lot!). I really think it must be my weight. That said, I was able to feed exclusively until we started solids, by feeding on demand and a lot, perhaps because I don't have the additional hormonal challenges of PCOS or other health issues. The silver lining - I think all that suckling on my slow boobs made her very attached to that form of comfort, and we're going strong still :)

Anyway, I love your blog, often find things of much interest and want to say thanks for sharing!

May 28, 2006 | Unregistered CommenterLeah

I looked for an email address to send this privately, but I couldn't find one so I'm leaving it as a comment. It sounds to me like you're saying lactogenesis II is pathological, but it's actually quite normal. Lactogenesis I is the development of colostrum within the breasts during pregnancy; lactogenesis II is when the milk "comes in," triggered by delivery of the placenta (though obviously there's a lag btw the two events).

Absolutely, PCOS/insulin resistance can contribute to problems with or failure of lactogenesis II. But lactogenesis (of both kinds) is a good thing.

May 28, 2006 | Unregistered CommenterJamie

well what we have used- fenugreek to increase milk production and it seems to work-- in India it is a food stuff and up to 50 grams can easily be consumed in a day so - the 1-2 grams/ day moms get in caps -- it is considered GRAS and I guess there are some studies to support it's use- the other suff is ok but does not work as good.
blood sugar- exercise 1/2 hr does some amazing things for regulation- eat low glycemic index foods-- you know blueberries fit into this category... now I will probably say the most controversial info- rule out dairy sensitivity/allergy- and the other one to think about is wheat sensitivity- but I would target milk first- and eliminate that from the diet-
any how other things that help birth blood sugar regulation- cinnamon 1/4 tsp at a time. Magnesium as a supplement just the RDA will do- at a conference I was at recently it was illustrated that in government studies on food production and consumption including foods from home gardens we as a nation have a deficit in magnesium- sort of a magnesium famine --- and magnesium helps to regulate blood sugar- is a smooth muscle relaxant and helps with how we manage calcium- B vitamins are co-enzymes in all sorts of metabolic functions including producing insulin- ( also helps with energy, alertness and depression)
Folate and vit B 12 levels drop through pregnancy, I think that a woman who starts with medium to low levels could end up with levels that are too low at the end of pregnancy-- there is a connection between homocystine levels and both these vitamins - and folate also has to do with production of clotting factors.
the Linus Pauling institute has some info on vitamins
http://lpi.oregonstate.edu/infocenter/

May 29, 2006 | Unregistered CommenterAnonymous

I want to comment about the metformin and tummy irritation.
When you eat foods that are high in carbs/fat while taking this medication - and don't drink enough water - - You WILL get an upset tummy. It's your body's way of working with the meds to inform you that you are eating things that are not in your best interest.
Of course, there are exceptions - but once I learned this bit of helpful information (eat correctly while taking the meds and drink plenty of water) my upset tummy was gone. I've successfully taken metformin for over 2 years and the only time I have an upset tummy is when I eat things that are not in my best interest.
As a side note - almost ALL of the varying symptoms that I was experiencing have gone away while being on this med....including my depression.

May 29, 2006 | Unregistered CommenterWash Lady

I'll have to look at the syllabus to see why (it was early when the session talked about it), but two separate researchers and LCs said NO FENUGREEK IS SAFE for women with GDM or DM - No amount at all is safe.

I'll check why and get back to you.

May 29, 2006 | Unregistered CommenterNavelgazing Midwife

take a look on Pub med-- Trigonella foenumgraecum ---
but what I was recommending is for milk production- Tierona Low Dog MD has been working for the National Institute of Health at the University of Arizona- on over here in Tucson and came and gave a lecture on safe herbs for breastfeeding( was to lactation consultatnts and allied health ) - Fenugreek tops her list-of herbs to help milk production-- and when she was questioned as to it's safety by the nurses she said only in America would there even be such a question- it is safe. She also said that if you have had any artificially flavored maple syrup it is fenugreek that makes the flavoring. --- she gave it a no reservation at the levels normally taken in the US certainly anything below 50 grams/day. and I would have to say that it matches my experience as far as what has helped my gals who have PCOS or suspect PCOS produce milk--- anonS
PS you may want to clip these off but am sending them along for you to look at

Mol Cell Biochem. 2006 May 23; [Epub ahead of print]

Long-term effect of Trigonella foenum graecum and its combination with sodium
orthovanadate in preventing histopathological and biochemical abnormalities in
diabetic rat ocular tissues.

Preet A, Siddiqui MR, Taha A, Badhai J, Hussain ME, Yadava PK, Baquer NZ.

Hormone and Drug Research Laboratory, Applied Molecular Biology Laboratory,
School of Life Sciences, Jawaharlal Nehru University, New Delhi, 110067, India,
nzbaquer@yahoo.co.in.

Trigonella foenum graecum seed powder (TSP) and Sodium Orthovanadate (SOV) have
been shown to demonstrate antidiabetic effects by stabilizing glucose
homeostasis and carbohydrate metabolism in experimental type-1 diabetes. However
their efficacy in controlling histopathological and biochemical abnormalities in
ocular tissues associated with diabetic retinopathy is not known. The purpose of
this study was to investigate the comparative efficacy of individual as well as
combination therapy of TSP and SOV in 8 weeks diabetic rat lens and retina.
Retinas and lenses were taken from control, alloxan-induced diabetic rats and
diabetic rats treated separately with insulin, 5%TSP, SOV (0.6 mg/ml) and a
combined dose of SOV (0.2 mg/ml) and 5%TSP for 60 days. Control and each
experimental group had six rats. Alterations in the activities of enzymes HK
(hexokinase), AR (aldose reductase), SDH (sorbitol dehydrogenase), G-6-PD
(glucose-6-phosphate dehydrogenase), GPx (glutathione peroxidase), GR
(glutathione reductase) and levels of metabolites like sorbitol, fructose,
glucose, MDA (malondialdehyde) and GSH (reduced glutathione) were measured in
the cytosolic fraction of lenses besides measuring blood glucose levels and
glycosylated haemoglobin. Histopathological abnormalities were studied in the
lens using photomicrography and retina using transmission electron microscopy.
Blood glucose, glycosylated haemoglobin levels and polyol pathway enzymes AR and
SDH increased significantly causing accumulation of sorbitol and fructose in the
diabetic lens and treatment with SOV and TSP significantly (p < 0.05) decreased
these to control levels. Similarly, SOV and TSP treatments modulated the
activities of HK, G-6-PD, GPx and GR in the rat lens to control values.
Ultrastructure of the diabetic retina revealed disintegration of the inner
nuclear layer cells with reduction in rough endoplasmic reticulum and swelling
of mitochondria in the bipolar cells; and these histopathological events were
effectively restored to control state by SOV and TSP treatments. In this study
SOV and TSP effectively controlled ocular histopathological and biochemical
abnormalities associated with experimental type-1 diabetes, and a combination
regimen of low dose of SOV with TSP demonstrated the most significant effect. In
conclusion, the potential of SOV and TSP alone or in low dose combination may be
considered as promising approaches for the prevention of diabetic retinopathy
and other ocular disorders.

PMID: 16718375 [PubMed - as supplied by publisher]
-----------------------
J Med Food. 2005 Winter;8(4):545-9.

Effect of supplementation of traditional medicinal plants on blood glucose in
non-insulin-dependent diabetics: a pilot study.

Kochhar A, Nagi M.

Department of Food & Nutrition, College of Home Science, Punjab Agricultural
University, Ludhiana, Punjab, India. dranitakochhar@yahoo.com

The effect of supplementation of a powdered mixture of three traditional
medicinal plants-bittergourd, jamun seeds, and fenugreek seeds-in raw and cooked
form on blood glucose was studied in 60 non-insulin-dependent male diabetics.
The patients were divided into two groups of 30 each. The patients of group I
were given the raw powdered mixture in the form of capsules; the patients of
group II were given this mixture in the form of salty biscuits. Daily
supplementation of 1 g of this powered mixture for a 1.5-month period and then a
further increase to 2 g for another 1.5 months significantly reduced the fasting
as well as the postprandial glucose level of the diabetic patients. A
significant decrease in oral hypoglycemic drug intake and decline in percentage
of the subjects who were on hypoglycemic drugs were found after the 3-month
feeding trial. It was concluded that 2 g of a powdered mixture of traditional
medicinal plants in either raw or cooked form can be successfully used for
lowering blood glucose in diabetics.

PMID: 16379570 [PubMed - indexed for MEDLINE]
---------------------------------------
I can't find her references right now - but there are 13 pages on pub med. --

May 29, 2006 | Unregistered CommenterAnonymous

here is an extensive review--
J Fam Pract. 2005 Oct;54(10):876-86.

Are Ayurvedic herbs for diabetes effective?

Shekelle PG, Hardy M, Morton SC, Coulter I, Venuturupalli S, Favreau J, Hilton
LK.

Southern California Evidence-Based Practice Center, Santa Monica, CA 90073, USA.
shekelle@rand.org

OBJECTIVE: To evaluate and synthesize the evidence on the effect of Ayurvedic
therapies for diabetes mellitus. DESIGN: Systematic review of trials.
MEASUREMENTS AND MAIN RESULTS: We found no study that assessed Ayurvedic as a
system of care. Botanical therapy was by far the most commonly studied Ayurvedic
treatment. Herbs were studied either singly or as formulas. In all, 993 titles
in Western computerized databases and 318 titles identified by hand-searching
journals in India were examined, yielding 54 articles reporting the results of
62 studies. The most-studied herbs were G sylvestre, C indica, fenugreek, and
Eugenia jambolana. A number of herbal formulas were tested, but Ayush-82 and
D-400 were most often studied. Thirty-five of the studies included came from the
Western literature, 27 from the Indian. Seven were randomized controlled trials
(RCTs) and 10 controlled clinical trials (CCTs) or natural experiments.
Twenty-two studies went on to further analysis based on a set of criteria. Of
these, 10 were RCTs, CCTs, or natural experiments, 12 were case series or cohort
studies. There is evidence to suggest that the herbs C indica, holy basil,
fenugreek, and G sylvestre, and the herbal formulas Ayush-82 and D-400 have a
glucose-lowering effect and deserve further study. Evidence of effectiveness of
several other herbs is less extensive (C tamala, E jambolana, and Momordica
charantia). CONCLUSIONS: There is heterogeneity in the available literature on
Ayurvedic treatment for diabetes. Most studies test herbal therapy.
Heterogeneity exists in the herbs and formulas tested (more than 44 different
interventions identified) and in the method of their preparation. Despite these
limitations, there are sufficient data for several herbs or herbal formulas to
warrant further studies.

Publication Types:
Clinical Conference
Review

PMID: 16202376 [PubMed - indexed for MEDLINE]

May 29, 2006 | Unregistered CommenterAnonymous

We don't use this for our pregnant gals just post partum for breastfeeding and I have looked and cannot find anything alarming- there is an analysis on the FDA web site (pdf) and this one from Abbott labs on pub med- I think that any problems are purely speculative- maybe something to do with the aromatics.. as I said before we are probably being successful with 2 grams/ day to increase breastmilk production- and consumption in the middle east can be as high as 50 grams/day. So quite a small amount dietarily . anon s

ood Chem Toxicol. 2004 Nov;42(11):1769-75.

Genotoxicity testing of a fenugreek extract.

Flammang AM, Cifone MA, Erexson GL, Stankowski LF Jr.

Ross Products Division, Abbott Laboratories, 624 Cleveland Ave, Columbus, OH
43215-1724, USA. ann.flammang@abbott.com

Fenugreek seeds have been used in traditional medicines as a remedy for
diabetes. Rich in protein, fenugreek seeds contain the unique major free amino
acid 4-hydroxyisoleucine (4-OH-Ile), which has been characterized as one of the
active ingredients for blood glucose control. Current use of fenugreek in
foodstuff has been limited to its role as a flavoring agent, and not as an
ingredient to help mitigate the blood glucose response for people with diabetes.
As part of a safety evaluation of novel ingredients for use in blood glucose
control, the potential genotoxicity of a fenugreek seed extract (THL),
containing a minimum of 40% 4-OH-ILE, was evaluated using the standard battery
of tests (reverse mutation assay; mouse lymphoma forward mutation assay; mouse
micronucleus assay) recommended by US Food and Drug Administration (FDA) for
food ingredients. THL was determined not to be genotoxic under the conditions of
the tested genetic toxicity battery. The negative assay results provide support
that addition of THL to foodstuffs formulated for people with diabetes is
expected to be safe. A wide safety margin is established, as anticipated doses
are small compared to the doses administered in the assays.

PMID: 15350674 [PubMed - indexed for MEDLINE]

May 30, 2006 | Unregistered CommenterAnonymous

My mom has Type 2 Diabetes so I have some info on alternative therapies and DM. According to my books, fenugreek has a significant impact on (lowering) your blood sugar levels, often to the point of needing to adjust your insulin regime. I suppose if your system is already topsyturvy with being in a childbearing year, the use of fenugreek could be problematic in someone with GMD or DM. I'll be interested to see if there is more to the story nm!

May 30, 2006 | Unregistered CommenterSarahthedoula

Thank you, Leah!

So many great comments and references. I haven't had a second to poke around the syllabus, but shall before the weekend is over. I look forward to hearing more about fenugreek, too.

Thanks to everyone for all the wonderful comments and resources. I will comment more as soon as I read more.

May 31, 2006 | Unregistered CommenterNavelgazing Midwife

Heya!
Such a wonderful post! I swear I learn morefrom you every time I go delving into your archives... Amazing stuff.

Hey, I write for another blog (www.sisterhoodsix.com) and we're about to have a carnival (very similar to Grand Rounds) on breastfeeding challenges. I'd love to include your post? Would this be ok?

You can e-mail the link to carnival@sisterhoodsix.com by July 15 (Saturday) or if you say it's ok I'll just link to it as I'm gonna be hosting.

Thanks again for sharing all your wisdom. :)
Louisa

July 12, 2006 | Unregistered CommenterLouisa

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