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Friday
Nov272009

Birthing Fat: Insulin

Preface:

This series of four articles/posts, combined, examine the issues surrounding obesity and pregnancy. As more and more women find themselves fitting into this designation, it begs to be discussed. This is not a scholarly series, yet does quote and refer to many studies and professional experiences. There is not a bibliography, but feel free to click the many links sprinkled within the pieces. Interspersed throughout, my experiences as well as other mothers I have spoken and worked with, flesh out a technical piece. While anecdotal stories do not tell the whole story, to many of us, neither do the studies. Therefore, I have chosen to make the series more accessible and enjoyable. I welcome comments and even advice. 

--------------  

Part II: Hormones  

No one likes being preached at, myself included. Here, I share information that might be helpful to women pre-pregnancy, prenatally and during their postpartum period. I hope it’s helpful. 

It turns out that hormonal issues can plague a fat woman’s desires to become pregnant as well as once she is pregnant and even during breastfeeding. The most common are insulin or thyroid disorders. I’ll leave the biochemistry discussion for the professionals, but do want to talk about the most common hormonal problem for obese (and more) women: Polycystic Ovary Syndrome. 

I really like this information from the Fertility Factor.

PCOS Symptoms: While cysts are the most common symptom of PCOS, some doctors will diagnose a woman with PCOS even when cysts aren’t present. In these instances, the diagnosis is based on the presence of other symptoms and hormonal abnormalities.

Symptoms of PCOS include:

       - Amenorrhea (cessation of period) or infrequent periods

       - Irregular bleeding

       - Infrequent or no ovulation

       - Cysts on ovaries

       - Increased levels of male hormone, like testosterone

       - Infertility

       - Chronic pelvic pain for six months or more

       - Increase in weight or obesity (most women with PCOS are overweight)

       - Diabetes; over production and inefficient use of insulin by the body

       - Lipid abnormalities (high or low cholesterol, high triglycerides)

       - High blood pressure

       - Excess facial and body hair growth

       - Male-pattern baldness or thinning hair

       - Acne, oily skin, or dandruff

       - Dark-colored patches of thick skin on neck, groin, underarms or skin folds

       - Skin tags in the armpits or neck.

and

While it is possible to become pregnant, women with PCOS tend to suffer a much higher rate of miscarriages. Estimates put the rate of miscarriages in women with PCOS at 45% although some believe the figure may be higher. However, experts aren’t sure why exactly this is. Fertility problems experienced by women with PCOS may be related to the elevated hormone, insulin, or glucose levels, all of which can interfere with implantation as well as development of the embryo. Additionally, abnormal insulin levels may also contribute to poor egg quality, making conception more difficult.” 

Polycystic Ovarian Syndrome (PCOS) along with Insulin Resistance (IR) (also known as Carbohydrate Intolerance and Syndrome X) are a common part of many fat women’s lives. Normal-weighted women can also have PCOS, but it is a much smaller number than the number of obese women. Doctors seem to be divided about what comes first, the weight gain causing IR or the IR causing weight gain and, possibly, PCOS (which not every woman with IR gets). Doctors do agree they are all intertwined, but don’t quite know how.  

As an aside, there are now lab tests to determine IR. The two available outside of the clinical setting are the HOMA (Homeostatic Model Assessment) and QUICKI (Quantitative Insulin Sensitivity Check Index). Both use fasting insulin and glucose levels to determine if there is IR. Instead of delving into the mechanics of these tests, if you’d like more information, please search and learn. We might want to know more about these tests because “Severe insulin resistance may increase rate of pregnancy and birth complications.” One of the best sites I’ve found regarding all three syndromes is InterNational Council on Infertility Information Dissemination (INCIID – pronounced “inside”). 

The Body Mass Index has long been a way to determine if someone is obese (or more), but has fallen out of favor in many medical arenas. Instead of using the BMI as a gauge for obesity, it is becoming more common to use the Waist-to-Hip Ratio. Dividing your waist size by your hip size, the smaller the number, it says, the less likely you will be to develop diseases such as diabetes, heart disease and hypertension. For women, the number needs to be as close to .7 as possible, but above .85 is when the risks begin climbing. For men, it is 0.9. Think of the apple shaped people you know; they are the ones most at risk. Beer bellies? Same. Women who look pregnant when they aren’t? Same. (My own belly grows the fatter I get, but just in the little weight I’ve lost recently, my upper belly is already smaller… helping me to keep going. I don’t like looking pregnant at 48 years old.) It is also believed that this body shape is demonstrating an IR issue, if not outright diabetes. Additional studies are being done to validate what these earlier researchers have found.

One message is weight isn’t always the best way to tell if someone is hormonally having a hard time or is healthy. There are many other ways to tell. My favorite way to see a person’s health is by doing lab tests, complete cholesterol, thyroid tests, fasting glucose, Hemoglobin A1c (discussed below) and now, Vitamin D levels. As lifestyles change, labs change… either better or worse. 

Learning, before you get pregnant, that you have hormonal issues can greatly alleviate any surprises trying to conceive or, in the sad case, if you have a miscarriage. If she does have insulin issues, finding a way to test for Gestational Diabetes is very important. 

Most of us reading this already know the controversies surrounding testing for glucose tolerance during the pregnancy. In 1996, Henci Goer wrote a treatise about such testing in “Gestational Diabetes: The Emperor Has No Clothes.” She speaks eloquently, taking bits and pieces of various studies, demonstrating that glucose testing in pregnancy is not only unnecessary, but can even cause women a great deal of discomfort. At the very end, she concedes, “Maternal weight has the strongest correlation with macrosomia rate; it makes sense to advise heavily overweight women to lose weight before becoming pregnant. Pregnancy makes extra demands on insulin production; to minimize the pressure, pregnant women should eat a diet low in simple sugars, high in complex carbohydrates and fiber, and moderate in fat. Moderate, regular exercise also improves glucose tolerance. Within the GD population lurk a few women who were either undiagnosed pregestational diabetics or who were tipped into true diabetes by the metabolic stress of pregnancy; a fasting glucose to screen for them might be prudent.” The article is oft-quoted (though most forget that last paragraph I shared), but copious amounts of research has come out in the last 14 years and as women have gotten fatter, testing might not be such a bad idea after all. 

What I have chosen to do in my practice is to do a Hemoglobin A1C for larger-sized women (over about 200 pounds depending on height) when they first enter care. The HgbA1c offers an average of the last three months’ glucose levels stated in a percentage point scale. 

HbA1c

Avg. Blood Sugar

HbA1c
(%)

(mmol/L)

(mg/dL)

5

5.4 (4.2–6.7)

97 (76–120)

6

7.0 (5.5–8.5)

126 (100–152)

7

8.6 (6.8–10.3)

154 (123–185)

8

10.2 (8.1–12.1)

183 (147–217)

9

11.8 (9.4–13.9)

212 (170–249)

10

13.4 (10.7–15.7)

240 (193–282)

11

14.9 (12.0–17.5)

269 (217–314)

12

16.5 (13.3–19.3)

298 (240–347)

 

The argument can be made that I should test all women instead of making a subjective bias against fat women… and in researching more now, it might be something I do. The HgbA1c can also detect the tendency towards hypOglycemia, not just hypERglycemia. I’d love to hear your thoughts about routinely testing everyone or if purposeful testing might cost the clients less (including anxiety) and yield more information. I’d love, too, to hear thoughts about an arbitrary weight guess to decide who does and does not get tested. I’d especially love to hear what midwives do in their own practices when it comes to GDM and testing. 

It’s important to know that, when it comes to the HgbA1c, different labs have different ranges, so be sure to know your own lab’s values. In general, under a 5 is a person with good glucose control. The higher the number, the less control her body has with glucose/carbohydrates. If I have a client with an HgbA1c above 6, we begin looking at the diet and exercise routines. Over a 7, it’s some serious counseling and the discussion about a Glucose Tolerance screen or Test begins. 

Kmom, a well-known pregnancy fat-activist, has an exquisite site regarding GDM. (She also has the Well-Rounded Mama blog.) She reminds us, “It is also important to point out that the HbA1c test CANNOT be used to diagnose gd in pregnancy; it does not detect blood sugar changes quickly enough for utility in pregnancy.” Meaning GDM can develop very quickly in some women (usually after the 24th week) and watching the HgbA1c alone only allows the provider to see the last three months’ average. On Kmom’s site, you can read about the various methods of testing (both pre-pregnancy and during the pregnancy) that might not include drinking the vile glucola. 

“… the U.S. Preventive Services Task Force, in May 2008, examined gestational diabetes screening and treatment, concluding that there is insufficient scientific evidence to advise either for or against screening for gestational diabetes. The task force also noted that a majority of the positive screenings are false positives, which increases a woman's anxiety, but that recommendations for exercise and watching weight gain during pregnancy could be a benefit to all pregnant women. Barton said the task force will review the new study's findings in more detail to determine if it needs to update its recommendations. The American College of Obstetricians and Gynecologists recommends that all pregnant women in the U.S. be screened for gestational diabetes. 

From the CDC’s Maternal and Infant Health Research: Pregnancy Complications, “Gestational diabetes mellitus, or GDM, is a carbohydrate intolerance leading to hyperglycemia (high glucose) with onset during pregnancy. It affects 2% to 10% of pregnancies in the United States. Although this carbohydrate intolerance usually resolves after delivery, up to one-third of affected women have diabetes or impaired glucose metabolism at their postpartum screening. An estimated 15% to 50% will develop diabetes in the decades following the affected pregnancy.” 

But what about the women who aren’t yet pregnant? As the years pass, I see more and more fat women struggle with infertility. In fact, one of the most common “fertility” medications now is Metformin, the medication used for women with PCOS and IR issues. Metformin isn’t like insulin, lowering glucoses in the short term, but helps the glucoses remain low over time. Remembering that fat women aren’t the only ones having IR problems, I am not saying that every woman sitting in the fertility clinics are fat or that every fat woman struggles with infertility. Instead, for the large-sized women who have struggled with infertility, Metformin is often the only “remedy” (besides losing weight) they need to begin ovulating again. (Nutrition & Exercise discussions will be in the next installment.) 

I’ve had three babies as a fat woman, one when I was morbidly obese and two when I was super-sized. (Super-size is an informal designation for when one no longer fits in the clothes in stores.) I had no problems getting pregnant, but I was also in my early twenties. The older the woman, the more ovulation difficulties she tends to have. Had I put off childbearing until thirty, I would probably not have been able to conceive without help (and not having the money, might have been childless). Once I was thirty-years old, I began having one period every six months or so. Before the gastric bypass in 2001, it was once every year or two. Being fat again, I am not ovulating, not having had a period for about eight months now (and even that one lasted less than a day). 

All three pregnancies, I “passed” my GTTs, even the 3 hour GTT with my first child. My kids were 9 pounds 4 ounces, then 10 pounds 6 ounces and then 8 pounds 13 ounces. I could pick apart and detail (and justify) the weights of my babies, but it would only be personally anecdotal and pretty boring for you. Know, though, that I walked miles during my third pregnancy and I know that made a huge effect on insulin production which brought her to a lower birth weight. 

Looking back, I believe I absolutely had glucose issues, but we didn’t know about PCOS or IR back in the olden days. The information I’ve read regarding women who pass their GTTs yet have Large for Gestational Age (LGA) babies, a great majority of them develop IR issues or even diabetes within ten years. True to form, my last was born in 1986 and by 1995, I was diagnosed with full-fledged Type 2 Diabetes. I joined the ranks of my father’s family, all of whom eventually died from complications of diabetes. In fact, back when my grandmother was pregnant with my dad in 1938, they didn’t even know about GDM, but I listened as the family bragged about my dad weighing almost 13 pounds at birth, hobbling his mother, who delivered vaginally, for over a year. Looking at the pictures of my dad’s early years, you can see my relatives’ stomachs pooch out more and more, sure signs of insulin issues, including diabetes. 

Another aspect of insulin issues that are getting to be more common are women with lactation problems. At the last two La Leche League Conferences I’ve attended, Lisa Marasco, IBCLC, the country’s leading breastfeeding educator regarding milk production, had sessions that included PCOS and IR as a main topic. In a great article entitled PCOS & Breastfeeding, “Marasco found that approximately one third of women with PCOS have normal milk supply. One third has an overproduction of milk. Another third have some degree of low supply, but only one third of these again (one ninth of women with PCOS) will have a real struggle to produce any milk at all.” 

Research shows that “mothers who are obese (with a BMI > 30) are less likely to initiate lactation, have delayed lactogenesis II (when a woman’s milk comes in), and are prone to early cessation of breastfeeding. Black women, with the highest rates of American obesity, have the lowest rates and shortest duration of breastfeeding compared to Hispanic and white women. Women who are overweight and obese have lowered prolactin responses to suckling. Women who are obese are at risk for prolonged labors, excessive labor stress, and cesarean birth, all of which delay lactogenesis II.” 

In the next post, I will talk about ways for women to help themselves and find help, before and during pregnancy as well as during the postpartum period. I’ll discuss the Glucose Tolerance Screen and Test, the options for testing as well as how a woman might choose to prepare for them. I know the information can be found in dozens of places on the Net, but I don’t think discussing the difficult, hard or dangerous sides of insulin issues should be left without solutions. 

In the last, fourth, installment (I thought it was going to be three, but I was wrong), I will talk about why all of this matters… not just the song and dance ACOG spits out about fat women and the risks to mother and baby, but also some interesting observations, my anecdotal experiences and a request for other providers to share their experiences as well. I do not arrogantly believe my knowledge is all there is. In fact, I know I am a blip of knowledge in a vast ocean of information. I want to gather pieces together and speak of them in an accessible manner; we all can use more information, right?

 

References (1)

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    - Navelgazing Midwife Blog - Birthing Fat: Insulin

Reader Comments (12)

Thanks, NGM, for mentioning that women with PCOS/IR have a difficult time breastfeeding! I have both, and struggled with fertility issues all my life (although not actively trying to get pregnant). When I became pregnant with my daughter, thanks to metformin, I was ordered off the med. I was also told that I could not breastfeed while taking it, so I didn't take it. I struggled to produce a mere 10 oz a day (by test weights) while pumping, taking reglan and fenugreek and nursing all day and night. I was so depressed, because I didn't know why my body was not able to do something so normal. Many people just didn't understand why I was upset- just switch to a bottle! However, that wouldn't have solved the source of the issue, and I really wanted to know WHY. I finally got in touch with Diana West, the coauthor of Breastfeeding Mother's Guide to Making More Milk (with Lisa Marasco). Through several long email conversations, she recommended that I start the metformin again. I did, and my production increased. However, by that time, I was in the process of weaning, and emotionally could not have withstood pumping again to increase supply. I nursed my daughter for 6 months, and I was happy with that. This pregnancy, I have continued to take the metformin (with a different provider-I switched to a CNM midpregnancy last time), although my endocrinologist wanted me off it as soon as I tested positive for pregnancy. I am currently 31 weeks, and my CNM is supportive of me remaining on the met, although she is sending me back to the MFM specialist to check for issues (relating to both the PCOS/IR and my thyroid problems) and wants to see what he has to say about staying on the metformin. Hopefully, he won't have an issue with it (my CNM doesn't seem to think he will, considering I seem to do better on it). I will cross that bridge when I come to it. And when my next child is born, we will see if the metformin therapy has any effect on my milk production.

I also am looking forward to reading what you have to say about thyroid issues and pregnancy and breastfeeding. I developed PPT, which was subsequently diagnosed as Hashimoto's. During my first pregnancy, my thyroid levels were very low (0.03, if I recall correctly), but one endo said this was just because of the pregnancy, and refused to treat it. When I was diagnosed with the PPT, I was sent to a different endo, and eventually I was treated for hypothyroidism and hashimoto's. This runs in my family, I have been told. I am being treated for the hypothyroidism in this pregnancy, and my levels have remained in the normal range with close monitoring by my endocrinologist. I have been told there is no way to predict if the PPT will return.

Because I had difficulty breastfeeding, I insisted that I get my thyroid function tested, and the PPT was found. Often, women who have trouble breastfeeding just switch to formula and don't ever find out if there is a significant medical issue hiding behind low milk production. It is only because I was a bit "obsessed" with breastfeeding that I found out what I know- and I am healthier for it. I just hope that all my hard work, tears and pumping aren't for naught- I guess I will find out if it has paid off when my next child is born, sometime at the end of January or beginning of February! Send some milky vibes and prayers my way, please!!

November 27, 2009 | Unregistered CommenterJennifer B.

I wish that the information you presented was broadcast more and far wider then it is. I am fortunate in not suffering any issue from being morbidly obese - at the same time I realize not having a wake up call makes me complacent. I remain an outlier physically but I do know that it will not always be so if I continue staying in my path of obesity, it is a life long health issue and should not be ignored - I worry about my health now effecting how mobile I am in the future (as you have had to contend with) and what pain I might encounter, which is beyond reproduction.

But, the clinic I go to does a glucose challenge twice during my pregnancies, once right after the first prenatal exam and the second when everyone else does it around 30 weeks. I don't think they are stressful at all, mostly uncomfortable because you have to sit around the damn lab for an hour - which is painful with the second test (fat person in chairs for the skinny) and boring and that means that there has to be child care for the kids I do have since it's unkind and unreasonable to ask preschoolers to sit with mom for that long. But as I said before, if it is for my health and the health of the pregnancy and it reassures my care givers I will do it willingly, getting medical care is a dance that should be undertaken with grace and care for one's partner - especially when you scare the partner.

November 28, 2009 | Unregistered CommenterEthel

Hi,
I am currently completing my postgrad diabetes in pregnancy paper. Plenty of the research points out that fasting glucose in the 1st trimester for high risk women will only pick up 40% of gestational diabetics and the OGTT test between 24-30wks will only detect 30%.

Routine screening is controversial when you consider trying to keep birthing a normal process which occurs to normal healthy women.

I also did some interesting reading around the subject of genetics and gestational diabetes where Maturity-Onset Diabetes of the Young are discussed (MODY2) mutations are usually asymptomatic. Most are detected during routine medical screening. Women with MODY2 mutations are often diagnosed during pregnancy. However, the outcome of the pregnancy can be influenced by whether the mother and / or fetus carry the mutation. When both mother and fetus are MODY2 positive, there is generally no effect on birth weight. However, MODY2 negative fetuses are carried by MODY2 positive mothers are typically large for gestational age due to maternal hyperglycemia. In contrast, if the fetus, but not the mother, carries the MODY2 mutation, their birth weight will be reduced by approximately 500g due to reduced fetal insulin secretion, which inhibits growth.

http://www.who.int/genomics/about/Diabetis-fin.pdf

Genetics and Diabetes

November 28, 2009 | Unregistered CommenterPam

Okay read your article quickly today, I'll have to come back because two kids and two family emergencies are sort of hindering my brain function and time allotment.

But...... I was already tested for PCOS. The year I got pregnant with my first I had them check because of the skin discoloration. I can't remember all the methods they used but I remember there were several ways of testing.... maybe labs and pelvic ultrasound of my ovaries.... nothing.

So, perhaps IR. Would that not also show up in labs? I'm guessing it's possible for it to not. I can't remember if I did a glucose test for the PCOS testing..... I'm thinking I did. I know I skipped it with both of my pregnancies. Midwives agreed that I never spilled any glucose in my urine or showed any other signs (ummmmmm yeah right now I'm thinking) so I skipped.

Wanna guess what shape I am.... yeahhhhhh you already know right, apple! And even though I eat healthy whole foods on a regular basis wanna guess what I ALWAYS follow it up with? What I am COMPLETELY addicted to....... simple sugars.... every day I have a good old helping of those.

Well you have me thinking now..... I'm wondering if I have those results from my PCOS testing in my charts.... think I do!

No problems breastfeeding here, and seem to get pregnant with ease..... but I'm still young. Hmmmmmmmmmm

November 28, 2009 | Unregistered CommenterSavannah

Amazing post, NGM. Informative and thought provoking. Thank you for pointing out the IR and GDM issues. So many women, including me, are or have been underinformed on the production of insulin and the impact it has on our unborn.

November 28, 2009 | Unregistered CommenterStaudtCJ

Pam: I want to know more! Does the combination of the fasting and OGTT combine to make 70%? Are the women who "pass" the fasting, tested later? Are the women who fail, tested again later, too? Or were they already tested and failed and considered GDM so don't take the later test, making the 30% ruling out the already tested and positive women; to me, if THAT is the case, then 30% is an enormous number, don't you think?

I appreciate what you shared... definitely information I didn't know and wouldn't have known to look for... but what do we DO with pregnant women? Just let all women not be tested because "only" 40% and 30% are discovered? How would YOU determine a GDM if YOU were in charge?

I mean this seriously... not snotty at all.

November 28, 2009 | Registered CommenterNavelgazing Midwife

Jennifer, I wasn't going to discuss thyroid issues at all; it isn't my specialty. I feel bad, but I really know so little about it (despite being hypoglycemic myself), I know I couldn't do it justice the way I feel I can with insulin issues.

But, I *am* glad you were persistent and discovered your thyroid disorder. You are right, too many give up without knowing why.

I am not an OB or a perinatologist, but if it were ME trying to have a baby today, I would choose to stay on the Metformin throughout the pregnancy and breastfeeding. To me, the benefit outweighs the risk. But, YOU have to work it out with your providers.

November 28, 2009 | Registered CommenterNavelgazing Midwife

Okay, I admit to almost no interest in the issue, and I didn't even read the whole article, but I just had to say GOOD FOR YOU for saying 'fat' instead of trying to be 'PC' about it! I hate how PC everyone tries to be all the time. I had to laugh the first time you used the word 'fat' because it was so refreshing to hear someone just go out and say it instead of using some pc term like 'overweight', 'women with high bmi' or even the more 'clinical' word 'obese'. I'm fat, I know it, and people who insist on being offended by terms that have always been used to refer to certain conditions annoy the bejesus out of me. I hate 'PC', and I'm cheering you on for not falling prey to it! :)

December 5, 2009 | Unregistered CommenterJespren

*laughing* Thanks for the kind words. Fat is fat is fat, right?

December 5, 2009 | Registered CommenterNavelgazing Midwife

That was a really great post. I am overweight and I have struggled to come to terms with how my weight may have negativley affected my three pregnancies. My first I had PPH and failed induction. My second was uneventful. I, like you walked like crazy durring that pregnancy. And had my smallest baby.With my third baby I was tested nagative for GD but had a LGA baby. I do wonder if I had insulin issues that were missed. I am determined to lose some weight before having anymore children, because of these issues.

December 5, 2009 | Unregistered CommenterKatie

I was diagnosed and treated for PCOS even though an ultrasound detected no cysts and the labs were all wrong. Turns out I actually had Cushings Syndrome-all the same symptoms, but different cause.

March 20, 2010 | Unregistered CommenterKristine

Thanks for taking the time to spread the good word on health care. As a medical professional I appreciate the time and effort people are putting into sharing their knowledge with the world. I love your blog. Keep up the good work!

January 19, 2011 | Unregistered CommenterDr. David Richards

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