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Saturday
Jun122010

Fat Obstetrics

On June 10, 2010, the Unnecesarean blog, had  a critique of an article about fat women in birth. The post, written by ANaturalAdvocate, is called “Do Overweight Women Need Separate High-Risk Hospitals?” and refers to the New York Times article, “Growing Obesity Increases Perils of Childbearing.” 

The blog article, henceforth called the “critique,” picks out bits and pieces of the (NYT) article, moulding it in a way that highlights (in her eyes) the horrors of fat phobia in the birth world. 

The gist of the article is that women are getting fatter and fatter and, because of that, labor & deliver floors are having to change how things work. Bigger gowns, sturdier and physically bigger L&D beds and operating room tables are becoming necessary, different/longer GYN equipment is being bought… all to

accommodate the obese obstetric patient. 

(A note about terms: I am a fat woman who uses the term “fat” to describe myself and use it as an adjective and noun (depending on context), not as a pejorative. I will alternately use the terms “obese,” “large,” “bigger,” “large-sized,” “super-sized [over 300 pounds {or so} or over a 50 BMI],” and possibly others. However, I am offended by the term “morbidly obese” so will refrain from using it. I apologize if any of these words offends you, but these are the descriptions/adjectives I am comfortable with and choose to use.)  

Interestingly, it seems each blogger translates the article very differently. ANaturalAdvocate spends an inordinate amount of time discussing the Body Mass Index (BMI) and its shortcomings. The Well-Rounded Mama says, in her post, “Exaggerating the Risks Again,” that the article is, “hyperventilating about the risks of ‘obesity’ in pregnancy. And it includes the typical distortions, exaggerations, and apocryphal personal stories as part of the usual tactics to scare fat women into either drastic measures to lose weight before pregnancy, into draconian interventions during pregnancy, or to scare them out of even contemplating pregnancy at all.” I, on the other hand, read that fat is taking on a life of its own in the obstetric world… and we can no longer ignore it. Even if it is a smaller portion than WRM believes, it is a growing (bigger each day) population that must be acknowledged and addressed. 

You would have to have your head in the sand not to notice how fat Americans (and those who eat the S[tandard]A[merican]D[iet] diet) are becoming. Look around! I’m seeing toddlers weighing almost 100 pounds, grade school kids with diabetes and teens with blood pressure issues. I was the fat girl in junior and high school… at 130 pounds! Now, the fat girl weighs a whole, whole lot more. “Childhood obesity has more than tripled in the past 30 years. The prevalence of obesity among children aged 6 to 11 years increased from 6.5% in 1980 to 19.6% in 2008. The prevalence of obesity among adolescents aged 12 to 19 years increased from 5.0% to 18.1%.” What are we turning into? 

All of us could go on and on about the causes of obesity and the precipitous climb in the complications associated with it, but, one thing all of us are aware of: there is no one cause –and no one answer to fixing the problem. 

WRM says, “Some folks really are fat because they eat poorly and don't get enough exercise, and some folks really are fat because they have an eating disorder.  But research clearly shows that fatness also has a very strong genetic component.  Some people have underlying hormonal or metabolic disturbances (like PCOS) that create a propensity to being fat and great difficulty in losing weight.  Environmental factors (easy access to highly processed foods, less opportunities for exercise) plays a role for some people, yet many thinner people eat highly processed foods and get little exercise but are not fat.” 

I squint trying to see what her point is. To me, all of those statements roll into one reality: People are fat. Whether the food causes the hormonal imbalance that causes the PCOS that causes the weight gain that causes the fat… or whether the heredity makes the woman have a propensity to getting diabetes and she’s one of the (financially) poor minorities and eats the cheapest food our country offers; fast and fattening –and she gains a few extra pounds that her pancreas cannot handle and she lives for 15 years with Insulin Resistance before she gets pregnant and, even though she passes her GTT, has a serious case of over-stressed pancreas and, undetected, steps into the realm of diabetic complications. 

WHO CARES WHERE IT COMES FROM?!? We know how to fix it. Say it with me.

That’s right. Diet & Exercise.

If I know this… if I write this… why am I still fat? Because the answer to “Diet & Exercise” comes with a thousand parenthetical asides. 

-(But, the ghrelin makes people hungry, especially if they’ve lost weight before.)

-(The Dopamine receptors don’t work properly and are fed by food, making it a delightful feeling to eat again and again.)

-(Because we live in a world with remote control televisions instead of migrating twice a year as our bodies are meant to do.)

-(Because the poorest of the poor are relegated to eating the shittiest of the food choices.)

-(It’s not safe to walk where I live and I don’t have money for gas to go somewhere else or money for a gym membership.)

-(People at the office bring fattening foods and I can’t help myself.)

-(Food is delicious; healthy food tastes like crap.)

-(My grandmother lived through the depression and forced me to finish what was on my plate and I hear her yelling at me with every meal.)

-(Eating makes me high.)

-(I’ve tried to lose weight a thousand times and it never lasts.)

-(My thyroid is out of whack.)

-(I have PCOS and it makes it too hard to lose weight.)

-(I hate to exercise)

-(My whole family is Hispanic/African-American/Asian/Native American and it’s normal for my family to get diabetes.)

-(and on and on and on and on and on) 

Eating today has become biochemical warfare. 

Sometimes I feel like I fit into every one of those categories above, including the so on, so on, so on one. 

If I can’t even get my own food issues under control, how can I sit here writing about pregnant women getting theirs in order? 

Because I believe we all have to work together to support each other in this. I believe the only way for fat pregnant women to get the midwifery, holistic care we natural, birthy people think they deserve is to offer it ourselves

Before sharing my ideas about what to do, I want to talk a little more about why we must create our own solutions. 

Do you know what the body looks like inside when the person is fat? Do you know there are great globs of yellow fat… just like fat on a steak, but softer and yellower… coating the organs, the intestines, the uterus and clinging to the underside of the bottom layer of skin? Do you know that vaginas in very fat women are full, as if they are swollen, more challenging to find a cervix because fat in the tissues “drops” the flesh downward, hiding it? Did you know that the fat inside the body is called “Visceral Fat” and that it is not an inert mass like the fat you can grab/pinch on the body (subcutaneous fat), but an alive collection of matter that secretes many hormones, including leptin and resistin

"Visceral Fat  

Visceral body fat is one of the two types of body fat. Visceral fat sits underneath the muscles and borders vital organs. This tucked-away location makes it possible to be fairly slender and still carry an excess amount of fat. Visceral fat is metabolized by the liver and transforms into blood cholesterol, making it the most potentially harmful to your health. Your diet and degree of exercise affect your amount of visceral fat.

Subcutaneous Fat 

Subcutaneous fat lies beneath the outermost layer of skin (epidermis) and serves as a shield. It is located nearly everywhere on the body but may be thickest in the abdomen, thighs and underarms. A certain amount of subcutaneous fat is vital to survival. For example, it keeps you warm when it's cold outside. An excess of subcutaneous fat is a sign of being overweight.”

Visceral fat and its hormones don’t just sit there. It secretes chemicals into the system, chemicals linked to changes in the endocrine system, including causing PolyCystic Ovary Syndrome (PCOS), diabetes, heart disease and some forms of cancer. “Meanwhile, when fat reaches the digestive system it breaks down in the liver. As it does this, toxins are released into the bloodstream. These can seriously damage organs such as the liver, causing fatty liver disease. This can lead to inflammation, the formation of scar tissue and eventually cirrhosis. It is also a risk factor for cardiovascular disease.”

Did you tune out? Isn’t this part so flipping boring? Like some text book or a newspaper article that we’ve read a million times and just skim over saying, “blah blah blah.” All that crap we couldn’t care less about?

Instead, let’s look at what visceral fat looks like inside the body.

This is an MRI scan of an “averaged-sized man who is 6-foot-2, weighs 174 pounds and…” has a BMI of 21.7. The visceral fat is in yellow. Subcutaneous fat is green and the muscles are red.

This is a better example, also an MRI. Muscles are in red, bones are white, organs are black and fat is yellow.

This is a woman who weighs 119 pounds.

Here is a woman weighing 245 pounds.

You can easily see both the subcutaneous and visceral fat. Note the visceral fat surrounding the body's organs. The visceral fat is not just sitting there, but is actively infiltrating the organs with a mad variety of hormones and chemicals.

I don't know how anyone can sit there and tell me a fat person is healthy. The fat person might not have labs that are abnormal at the moment, but, moment by moment, those organs are being transformed into liver disease, cancers, diabetes, thyroid problems, heart disease and more.

Because I get an enormous amount of flack every time I say the vagina is fat, please take a gander at the fat around this one woman's (non-pregnant) uterus. Fat has weight and the weight presses down, pushing the tissues inward; vagina included.

Before you say, "But this is just one example," let me share with you another three photos of MRIs, the first is a normal amount of visceral fat, the second, a moderate amount and the third, a large amount of fat.

 

In this last MRI, the blue is the liver, red, kidneys, green, the spleen and pancreas. The white is the visceral fat.

I show and say all of this because I am so, so frustrated by everyone screaming, “FAT PHOBIC” whenever someone brings up the issues caused by fat. Of course I acknowledge fat phobia in our culture. I experience it almost every day, but that doesn’t mean we should ignore what is happening in our own, pretty isolated, natural birth community. Instead of pointing fingers outside, blaming the press, the rising cesarean rate, the insurance industry, the people who make bigger beds, the bariatric surgery people, the diet pill companies, why don’t we just hunker down and DO something for and with each other? Can’t we just admit there is a problem and we do have to figure out how to take care of our own? Simply having “fat positive” websites isn’t enough. It’s fine and dandy to feel great about yourself at any size, but really, does that eliminate the truth about what our fat is doing to our bodies? 

I propose that we develop groups for each other, places where we can talk, cook with each other, learning new ways to eat fresher and cleaner, places where we can walk with each other, encouraging each other during our pre-pregnancy, pregnancy and post-pregnancy times. I want a place that doesn’t make fat a bad word, that is filled with women who accept the reality of being unhealthy/fat/obese/super-sized and who want to do something about it. The groups of women can have diabetics, gestational diabetics, women with no medical problems at all, women who feel they can do more for their babies during the pregnancy… a place where there is zero judgment about fat and health, but a common commitment to working with each other – the only goal, to feel better, to get visceral fat out of our bodies (without dieting!) and be ready to parent our babies as gloriously healthy as possible. I haven’t come up with a name yet… I don’t want it to be “health,” “thin,” lose weight,”… words like that; I’m still experimenting. 

I’ll start. I’ll gather together women, even if it is one or two, and start some sort of group where we commit to being stronger and more alive by using food as energy and increasing even that with movement (exercise). 

I’ll start. I’ll start with myself.   

 

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Reader Comments (36)

Nice article. The visuals really do a lot to bring the matter up close and personal. I think you have a great idea of forming groups to work together on this. Not sure if I can contribute much IRL, but I'm happy to share recipes and stuff online. My husband had heart issues and diabetes, so we have been spending the past few years learning to eat better. It has helped him lose some weight. I'm not very big, but I spend all day writing so I am also trying to remain healthy with my extremely sedentary job. My biggest problem is my abdomen. Since it stretched so many times, now it is just big. I know I need more exercise... the problem is fitting it in my day. :P

June 12, 2010 | Unregistered CommenterToni

I am very impressed with this post, Barb. And you probably already know this, but it means so much more (imo) coming from someone who knows what it's like to be fat. I thank you so much for your courage to apply your advice to yourself and your willingness to go where so few are willing to go.

Did you see the Dr. Phil episode a few months back with a panel of people talking about fat-phobia? I had previously been introduced to Meme Rogers a short while before the Dr. Phil episode, and as a fat girl myself, I gotta say that while that gal has some serious issues of her own, she is not wrong to say that it's unhealthy to be fat!! (Though I don't agree with her uncompassionate, brash, rude way of going about her "campaign." I personally think she's a loon, but the things she says about obesity are usually true!) It was so bizarre watching the women who were on the side of panel saying, "You can still be fat and be healthy!! Just leave us fat people alone!!" I could relate to all their pain, all their struggles...and yet, I 100% completely disagreed with them in regards to their views on fat and obesity. They kept trying to pull out the "I'm fat and I don't have any health problems" card. But I kept wondering, "You're 'healthy' now, but for how long? How long till you develop diabetes? Hypertension? Heart disease?" So sad. They are using their hurt and pain as defenses for staying unhealthy...all while trying to convince other fat people to stay fat because it's not necessarily "unhealthy."

I am 31, a little over 200 pounds and have hypertension. That's not healthy and there's no way to get around that fact. I am learning to accept and love myself more, but I know I am not ever going to be my "best" at this weight--for myself, my family and my future. Period. I look forward to the development of your plan!

June 12, 2010 | Unregistered CommenterSarah B

Well said, Barb. You've said what's been on my mind, only far better than I could articulate it. Count me on board for forming groups- I am more than willing to offer my knowledge as a fitness instructor/personal trainer.

June 12, 2010 | Unregistered CommenterLori

I totally want to join your group. I know that I'm a fat girl, and I'm honestly sick of people trying to down play my weight because they are uncomfortable with the the term fat. I love myself, but I want to be healthy for myself, my husband, and my children. Being large HAS made my pregnancy's more difficult, and my labors longer. It is my gaol to lose weight and be a healthier me by time I'm 30. I just turned 29 and have lost 12 lbs! Only 100 to go!

June 12, 2010 | Unregistered CommenterAngie

I appreciate this post. I definitely feel that the original article was kind of fear-mongering for pregnant fat women, and that sending very fat women to high-risk hospitals to give birth WILL NOT fix anything and will probably lead to more maternal injury, preterm infants and unnecessary c-sections...it doesn't change the fact that MANY fat women can be a healthier weight. When I brought this up in a comment, however, I got responses along the lines of "I eat right, exercise, and I'm considered morbidly obese.." etc.

Okay, I have fat friends. We all do. Honestly, only one of those is fat DESPITE her lifestyle. She eats healthier than anyone I know, works hard cleaning for a living and gardening, and is still way up on the BMI. I'm sure there' s something going on in her body that makes it hard for her to lose weight. The others....well, they're fat BECAUSE of their lifestyle. They don't exercise and they eat out A LOT, some of them almost every meal. I would never judge them for their choices, but if I were in their shoes I would hope that I'd be able to own up to it and make a change for the better.

Oh, and the whole issue with the BMI chart...no it's not a perfect test; I'll be the first person to admit it...but the woman in the article was 5 feet tall and 261 pounds! I believe one blogger said that the person in the article "wasn't even that large", or something like that. The reality is that she was very large and no doubt that was the cause of many of her complications; it's not a conspiracy to make fat women feel bad.

Part of the problem with the article is also the title, particularly the words "perils of childbearing". In this day and age the perils of childbearing are very rare, but of course if you start with perils in "normal" women, then there must be much worse perils in very large women. I do agree that there should have been more statistics in the article. But, we all know that people get bored with statistics, so they almost never include those in these mainstream articles..:/

Personally I have struggled with weight issues my whole life, and even though I'm slightly in the "overweight" part of the BMI, I work very hard to keep myself there. We all have to take responsibility for our actions and be able to admit the truth. I supposed it's part of my personality- I'm very introspective and I don't like to fail. During my pregnancy I ate well and kept up my regular exercise routine right up until I delivered (in less than 5 hours, no less!). I gained 30 pounds, which would put me above the 30 BMI, but I lost most of it in the first 2 weeks pp.

Like you said, there's a long list of excuses that people will give for remaining fat, but it's a small minority that will really need something stronger than diet and exercise to help them be a healthier size. Notice that I didn't say thin- I have finally accepted the fact that I will never be thin and healthy, but I can be a healthy weight for my genetics.

June 12, 2010 | Unregistered Commentersara

honestly this article really scared me being substantially overweight and newly pregnant , is their really anything i can do while pregnant to help myself and my child?

June 12, 2010 | Unregistered Commenterdelma Moreno

I was listening to a fascinating NPR show a few months back about a Mayo Clinic researcher James Levine who investigates NEAT (Non-exercise activity thermogenesis)--basically, the energy we expend in non-exercise/non-cardiovascular activity. The energy we would have been expending all day long doing various menial tasks before industrialization and automation took over. The energy that certain social groups (Amish, some Mennonites, etc) have chosen to keep expending by avoiding electricity and cars and indoor plumbing.

Anyway, his solution isn't to try to turn the clock back and tell us to live like our ancestors--because that's not realistic for most people today--but to find new ways of generating NEAT for people who work in sedentary office jobs and who sit most of the day. He has invented a simple and inexpensive treadmill desk. You stand up and walk veeery slowly (1 mile per hour) at your desk, all day long. Just by doing this, you burn 800 extra calories per day.

Anyway, he's doing some really neat stuff because it's inexpensive--he's trying to make it so offices can actually afford his "furniture" for their employees--and easy and fits into the lifestyle of so many westerners.

Read more about his research here: http://mayoresearch.mayo.edu/levine_lab/

June 12, 2010 | Unregistered CommenterRixa

More links on NEAT:
http://www.mayoclinic.org/feature-articles/fidget-low-metabolism.html

Levine's office of the future:
http://www.mayoclinic.org/feature-articles/levine-office-of-future.html (with a slideshow and short video)

4-min NPR feature on Levine's research:
http://tinyurl.com/25eed8c

Good food meets NEAT: The Splendid Table interviews Dr. Levine at his treadmill office:
http://tinyurl.com/24btbfs (includes link to the podcast)

June 12, 2010 | Unregistered CommenterRixa

You know what got me about that story in the NYTimes? The fact that the premature baby featured was being fed formula. Who knows why his mother couldn't breastfeed him, but they should at least be able to procure human milk for him...instead they're just laying the foundation for more obesity in the next generation. Ugh.

June 13, 2010 | Unregistered CommenterVW

Awesome as always! :)

June 13, 2010 | Unregistered CommenterRéka

As someone who has gone from a BMI of 21 to a BMI of 33 in 4 short years I thank you. I too have told myself all the excuses under the sun as too why I have gained so much weight (divorce, study, starting shift work, over 40 now, too hard, too tired, not enough time....) but have been inspired by your post to do something about it NOW.
I am a midwife and love my job but how can I hope to do this for a long time if my joints are being constantly stressed by excess weight?
I am sitting down tonight and writing goals and affirmations for my new lifestyle. Thank you, and I hope your reclaiming control of you life goes well!

June 13, 2010 | Unregistered CommenterSue

@Rixa - the NEAT sounds fascinating!! I *love* the idea. He'll need a bike version for folks like me who've already ruined their feet enough that a treadmill isn't possible, but I really, really love the concept. And he is right... even walking to the store (often recommended) isn't going to happen - too far, too cold, too hot, too dangerous, too time consuming, etc. I really think his ideas are great. I can't wait to read more. And I will surely pass on the info!

But, Rixa, what did you think of what I wrote? Did I do okay for a start?

@Delma - you absolutely can do something now! No being worried!

The first, and one of the most important things you can do, is to walk at least 15-20 minutes after every meal, including breakfast. You might have to schedule food intake more often, but it really, really can make a difference. Not (just) to burn calories, either. The walking nudges the pancreas to push out insulin in an easier and more efficient way. The pancreas isn't freaked out by all the food that needs to be metabolized, but can gently take it and help make it fuel instead of fat. One long walk at night is not the idea! It really does need to be in shorter (at least!) spurts after eating. If you can go longer, by all means, do so!

Also, making sure the carbs you eat taste like tree bark (haha)... that they are whole grains (not whole wheat!)... no rice that isn't black or red... no bread that isn't whole grain... no potato unless it is orange... no soft fruits; berries and colorful, harder fruits instead. AND NO JUICES! AT ALL! No Jamba Juice. No orange juice. No apple juice. If you want the juice, eat the fruit. The fiber in the fruit slows things down considerably. That's why the softer fruits (mangoes, papayas, peaches) push the glucoses higher - because they are eaten without the skin. If you eat the skin on peaches, that helps. (I know it's summer... fruit is delish!)

Just these few things can transform your pregnancy. I really do hope this helps you feel more empowered. Let us know how things go! We're all on your side.

June 13, 2010 | Registered CommenterNavelgazing Midwife

Barb--this issue is so hard to tackle. I do agree with you that the "fat is healthy" part of fat acceptance doesn't ring true. How do we talk about obesity without the moral judgments, guilt, and defensiveness that inevitably follow? Weight/fatness/thinness is both an individual and a social issue, and both of these aspects need attention and, ultimately, workable solutions. I feel especially sensitive talking about this, since I am not overweight and thus will be accused of not understanding how hard it is to lose weight/maintain a healthy weight/etc.

Dr. Levine made a point that it is entirely natural for most people's bodies to store extra food easily. It's just that until about 100 years ago, most people didn't have that opportunity. But the combination of industrialization, mechanization, cheap sugary/salty/fatty processed foods, decline of home cooking, sedentary lifestyles, food advertising, etc etc etc have combined to form the perfect deadly storm. The more I think about his work, the more I am convinced that it's probably the most promising way out of the obesity problem (in conjunction with other current movements such as slow food, organic, eating local, etc). Everyone can find ways to add extra "fidgeting" into their daily routines. You can go all-out and try to convince your employer to adopt treadmill office furniture. But you can do smaller things: instead of sitting on a chair, sit on an exercise ball and bounce/rock constantly. In your case, Barb, see if you can rig up a desk or workstation high enough to use while sitting on an exercise bike (and pedaling slooowly all day long).

We also need to take a holistic approach to weight and health and obesity and remember that the foundations of a healthy weight and physiology begin with breastfeeding.

I feel very fortunate because I grew up in a household where we ate all homemade food. We got to eat fast food about once a year as a special "treat" (which meant one hamburger each and sharing a little thing of fries with several siblings--no soft drinks, just ice water). We didn't drink pop at home, or even much juice except for special occasions. Candy wasn't really allowed except for occasions such as Halloween. Occasional desserts, but definitely not every day. No sugary cereals, no junk food, very little processed food (although we went through a stage as children where we LOVED mac & cheese and fish sticks, so for a while my mom relented and let us eat these things when she had lots of little ones at home). So overall, we ate what would now be called a whole food diet.

June 13, 2010 | Unregistered CommenterRixa

Thanks - great post.

I am one who feels that it IS a big deal... I don't know how anyone could deny that, especially anyone who works in health care.

I strongly believe that this is one of the big reasons we're seeing more complications/interventions/cesareans/etc. in obstetrics, evidenced by, well, seeing it every day.

I think that people have a responsibility to eat properly but it also seems like a bit of a conspiracy by large food manufacturers who surely know that their food is basically addicting (sugar, salt, etc.). Sugar gets you up (yay! feel great), then we crash and CRAVE, must have more of the product to feel ok again.

1) Try to eat single-ingredient foods as much as possible, people!
Look at the label, if you can't pronounce it, DON'T buy it.

2) Avoid the middle aisles of the grocery store as much as possible.

As an example: parents, did you know that a serving of Fruit Loops has as much sugar as a Kit Kat bar? And that's a 1/2 cup serving - pretty much everyone is probably eating a bigger bowl than that. And that's not to mention all the other additives and unpronouncables in it. Switch to plain oatmeal (add your own extras - a reasonable amount of unrefined sugar, fruit, etc.), which is CHEAP and so much better. And there are SO many more delicious (and cheaper) options: whole grain baked stuff like pancakes, muffins, etc., eggs, fruit, etc. etc.

Almost everyone will have far fewer physical cravings when doing just these two things as a start; you will also feel fuller longer with the complex carbs/fiber you will get by default if eating this way.
Don't be pawns for large food corporations (and then, large pharmaceutical corporations)!

Another good website in www.pyramid.gov - it has a LOT of tools to help.

Probably most of you already know this... maybe someone will see it who doesn't, or doesn't realize how important it is.

June 13, 2010 | Unregistered Commentermitchsmom

This is a great article Barb. The pictures really bring to life what you are saying in a way that the words don't, as you've said, we just gloss over blah blah blah our health WHATEVER! But the photos and your explanation really brought it home. Sharing!

June 13, 2010 | Unregistered CommenterStassja

I've been a long-time lurker here, as i'm studying to be a doula and later on a midwife, and i do wonder what your opinion is on this topic of someone like me, who eats nothing but good healthy foods(i love the way health food tastes), nothing overly processed, not much meat (just the occasional piece of chicken or fish), only whole grains, lots of veggies and fruit, drinks lots of water, and i exercise everyday by bellydancing and/or swimming and walking everywhere(i dont own a car) and chasing my 17mo twins around, but i am still considered medically morbidly obese. and im not loosing any adipose tissue at all. at 5'5" i'm still 260 and ive been living healthy as long as i can remember, just about. i was just curious hat someone in my position is to do?

June 13, 2010 | Unregistered CommenterAradia

@Rixa - I've decided to quit being all politically correct about this weight issue. I'm sure I'll be smacked around some, but who cares. Instead of worrying about thin women "not understanding," I'm accepting that thin women have issues in *their* lives that aren't related to weight that are challenging for them to change and maintain. I am tired of using "fat-phobic" excuses and just want to get ON with it already. I will work very hard to never say again, "You just don't understand." Instead, I will open my heart and mind and think, "Maybe they DO have something to offer."

And what a great childhood! My mother, too, made lots of foods from scratch, but they were eclairs and donuts and sugary breads and such. And then, as the parents left us to our own devices, fast food became more and more a part of our lives. *sigh*

I look at my 49-year old body and think sometimes, "It's just too late," but I don't have grand-kids yet and I want to see them SO badly, I am willing to do *anything* to play with them on the floor. They are my motivation. Not me, anymore. Whatever works, right?

Aradia: it must be *so* hard, doing "everything right" and still being a big girl. I was a 350-pound vegetarian, but I ate several McDonald french fries a day. For YEARS. Barring the fat propensity to ignore a slew of foods that go into our mouths, the next thing to do is to lower the calories/amount of food you eat. Juices? No more! Being meticulous about those tree bark carbs being the only ones allowed in the house, and, despite all that walking you are surely doing, doing something else besides walking.

We have to remember that the body acclimates easily and quickly. If you are walking the kids to school every day and chasing after the toddler, it doesn't take but a minute for the body to say, "Oh, THAT'S what she's doing," and for the new set-point to install itself. Our bodies are meant to do different things. Chop wood, walk to the river to get water, dig trenches, traverse the woods looking for berries, building houses, etc. Doing the same thing over and over... working as a waitress, for example... no longer "counts" as exercise. Sucky, but true.

Does that help some?

June 13, 2010 | Registered CommenterNavelgazing Midwife

An interesting post, but I'm not sure you're responding to the main thrust of Unnecesarean's critique of the article. It seems to me that her main point was that treating seriously overweight women's pregnancies as disasters about to happen is just as detrimental to their health and to their babies' health as treating a thin woman's pregnancy that way. Of course fat women are more susceptible to developing certain problems, and many of them begin their pregnancies with health concerns that are rarer among thin women. But that does not mean they will all have those problems. In fact, in the many examples Unnecesarean gives, the risks among seriously overweight women, while greater than among those at a healthy weight, are still very low. And we already know that interventions often cause their own problems...Uneccesarean points out that it is even more true for seriously overweight women because of how they are treated during prenatal care and through delivery. So what I think she is saying, and what I would argue for, is that being overweight and pregnant is a factor that ought to be included in a woman's prenatal care, without making nasty assumptions about what that means for her pregnancy or about what sort of person she is. That should be the standard for all pregnant women. No fear-mongering, no preemptive moves. No treating women as the problem.

Midwives in particular are great at encouraging all moms to make healthy choices about diet, exercise, rest, etc. Seriously overweight moms ought to get more of that sort of encouragement and information, not treated as if they are bombs that will explode any minute. It is hard enough for a woman of more moderate weight to get support and information for a healthy pregnancy and delivery. If we, by sending all seriously overweight women to a special, even more highly medicalized facility, treat them as too fat to give birth like the "regular" women, we're not treating them as individuals who deserve respect and care that is appropriate for them rather than their demographic. Being overweight, as you so clearly point out, has major health consequences. And it doesn't help people get healthier if we close our eyes to that fact. But it doesn't help pregnant women give birth if we cull the overweight ones from the herd and send them to a special processing plant for ludicrously high levels of interventions, whether individually warranted or not.

For birth in America, I think that how the system treats overweight women in birth is a sort of canary in the coal mine. And folks, I hear the fat lady singing...

Right now, the maternal health care system uses any excuse it can find to "make" women lie still and be good little patients. We do not need to give them more leverage over any pregnant women so that they can make more rules about who is allowed to do what. Instead, we should expect (and demand) that those who care for our health in pregnancy and childbirth treat us as individuals with specific needs and health challenges, no matter what size we are.

Oh, one more thing to think about: separation is inherently unequal, right? I think that risking out the fat women and funneling them into specialized treatment centers will lead to them being treated as fat first, people second (and as mothers, last?). Not a good thing.

June 13, 2010 | Unregistered CommenterMelissa

Barb- I know you spent a long time writing this article. I have been continuously refreshing my google reader hoping to find it! I want you to know that every moment you spent was so worth it. You managed to take "fat" from a one dimensional word with so much baggage, to a 3-D, real thing. WOW, is all I have to say. Thank you for this post. I know I will be thinking about it over and over as so many doors have been opened in my mind!

June 13, 2010 | Unregistered CommenterVanessa

Thanks for your take. I tend to agree with Melissa, though, that the critiques are more about fat phobia playing out in the maternity care system v. is being fat a health risk or not (although your point is well taken that some things mentioned in the critiques are leaning that way). Did you see Uppercase Woman's response? I liked that one, too. Re: the article, I kept wondering, well is this just fat phobia or is there a grain of truth?

For Aradia and others struggling, I know that for me, no matter how active I am or how well I'm eating, I don't lose a single pound unless I'm logging my food. I use the free tools at sparkpeople.com. It is so eye opening to see what I'm really consuming and the logging holds me accountable. It also helps me learn how to make little tweaks here and there to consume fewer calories and still be satisfied. Speaking of which, I need to get back to this today. Weight issues are so damn hard and like Rixa points out, our culture and lifestyle is set up against us. We really do need to support each other on this.

June 14, 2010 | Unregistered CommenterRachel

I understand about the Fat Phobic part of the article/blog pieces. I purposefully set that aside to get this one out. "Fat Phobia" is coming next (if the fat muse keeps going!).

I felt I needed to touch a part that was either being ignored or not getting enough attention. It is merely what fell on the paper.

I also felt it was required to lay the foundation for a Fat Phobic piece.

June 14, 2010 | Registered CommenterNavelgazing Midwife

Just a question because I am curious - do you accept obese moms in your practice?
Because while I agree with what you have said for the most part - I would shy away from your services for fear of harsh judgment.
Do you think there should be a weight cut off for fat moms seeking a homebirth?
I admit openly that while pursuing a homebirth for the first time - I have intense anxiety weighing in with my midwife - anxiety like I never experienced with my OB

June 14, 2010 | Unregistered CommenterJanie

Harsh judgement or real discussions? You think I am judging? Hardly. What I *am* suggesting is we stop tip-toeing around fat/weight and discuss it like it really *is* sitting right there in the room. It doesn't supercede the pregnancy, but becomes a part of it -as it should.

No more would I dismiss/ignore obesity than I would a woman with an abuse history. Pretending it isn't there/doesn't exist creates an air of "this doesn't deserve to be looked at and paid attention to."

Yes, I absolutely take obese women (ask my clients!). But if they come to me expecting not to work on creating a healthy pregnancy (and that means *anyone*!), then I am not the right midwife for them.

Judgement? Absolutely not. Attention? You bet.

June 14, 2010 | Registered CommenterNavelgazing Midwife

Just wanted to suggest the word "nourish" for your naming thought process.

June 14, 2010 | Unregistered CommenterTatiana

Hi!

Just a question because this post reminded me of previous ones where you discussed vitamin D and willing to change your diet after viewing the movie about the industry of food.

Any follow-ups? Does it still prompt you long-term to cook from scratch, for example?

I don't comment much but I read you often; thank you for this blog I absolutely love!

June 16, 2010 | Unregistered CommenterOphélie

Barbara I wonder how the centering model of prenatal care might work. Instead of herding women off to the special "obesity wards" why not group women due around the same time together. You're right... it has to be women helping, supporting, guiding their peers NOT the medical world coming in and culling out yet another "high risk" group.

I'm not saying that larger szed women don't have certain risks because I know they do but they do not need to be segregated.

I do think some of the things mentioned in the article make sense though. It only makes sense to have tables, gowns etc in sizes to fit. I also think close monitoring might be warranted for cerain conditions, such as diabetes etc. But not all the monitoring has to be high tech. If palption is difficult and ultrasound is hard to read, could kick counts be used as an adjunct indicator of fetal condition?

June 16, 2010 | Unregistered Commentermrsculpepper

For my own group, I came up with Visceral Vixens. And thought of Belly Babes and... shoot, something else I can't remember at the moment. Hrm.

Healing is great! "Healing Hearts" - "Healing Happies" - ("Healing Hippies?" That'd be me, too!) - "Partners in Healing"... what else?

I think Centering is a great idea. I tried it for a very short time, and really liked it, but fell (too easily) back in the old groove. What's nice is, the women who Centered together, STILL see each other 3 years later. I also *loved* having my Mothers' Support Group. Those women also see each other years later. Some are 6 years old now!

There needs to be *A* way... *some* ways... to bring women together where they can talk openly about their experiences. And feelings. And concerns. A place that isn't like therapy, but a comfy place for everyone to BE and explore the variety of ways to *be*.

@Ophelie - I *am* motivated to keep going. Am I always perfect? No, and that bugs me muchly.

I had an epiphany the other day. I hate lettuce. And I'm not going to eat any more of it. I like all the other things that go on salads, but the lettuce causes me to drown it in salad dressing. I'd much rather have no lettuce, lots of veggies and little dressing. It was a FREEING moment to come to that decision. All my life, I've been admonished to eat salad, eat lettuce, eat dark green leafy vegetables... blah blah blah. And I've never really liked any of them at all.

So, instead of worrying, putting off, eating a salad, I have re-named a "salad" to mean all those yummy things that go IN a salad, but no lettuce. I can do that!

June 16, 2010 | Registered CommenterNavelgazing Midwife

Rixa shares this post of hers:

http://rixarixa.blogspot.com/2010/06/when-diet-and-exercise-fail.html

June 17, 2010 | Registered CommenterNavelgazing Midwife

I'm a fat woman. (I'm also on the "reclaiming the word 'fat' as a value-neutral descriptor" train.) I've been plump since puberty, fat since I quit smoking, and gained up to 275 before we finally got my thyroid under control. I have a lot of issues keeping me fat, but the biggest are that I eat too much crap and I don't exercise enough.

The only circumstances under which I have ever lost weight were 1) when I was getting regular exercise literally every single day and 2) when I am pregnant. With my first pregnancy, I ended the pregancy weighing 12 pounds less than I did when I started it; post-partum, I kept losing weight until we introduced solids to my daughter. Right now, I am 19 weeks pregnant and I weigh 25 pounds less than my conception weight.

The pregnancy thing kind of baffles me. I certainly don't diet when I'm pregnant; that way lies madness. I try harder to get some movement, but last time I had horrific SPD from 13 weeks on and even this time my "exercise" is basically "park at the other end of the parking lot." I do gravitate more towards fresh fruits and vegetables when I'm pregnant, though, and I think that may be the big deal.

So! For those who would like to improve their health -- and my health right now is pretty great, weight not withstanding, but my dad is diabetic and I have no illusions about what's coming -- I vote for starting by adding, not subtracting. Add vegetables to every meal, even breakfast, and add 20 minutes or 2000 steps of exercise to every day.

And as for those vegetables? Prepare them in a way which is tasty to you. Even if that involves adding fat to them. Adding fat to vegetables makes them more caloric, but it does NOT make them less nutritious! There's the much-vaunted comparison about how a salad with dressing at McDonald's has more calories and more fat than a Big Mac, which it does, but it also has less sugar and more nutrition.

The more vegetables I eat, the less sugar I want to eat, and the fewer refined carbohydrates I want to eat. I actually looked at a cupcake yesterday and was viscerally repulsed by the idea that it would be good to eat, and this morning I ate the breakfast I craved -- sliced heirloom tomatoes on rye crackers with cream cheese and sea salt. If you have the option of delicious vegetables prepared deliciously, trust me, you will come to like them and then love them and then crave them, and that is worth the fat or whatnot that you use to prepare them, even if the calorie counts don't seem that different.

June 19, 2010 | Unregistered CommenterKathryn T.

I appreciate your response. But can you tell me exactly the science of how you get the visceral fat out of your body (if not through weight loss)? I currently practice HAES and I believe that for the bulk of people (fat, thin, inbetween) that it (HAES) is the only sane answer to an unrealistic diet industry and to the paranoia surrounding women and eating. It is emotionally and physically empowering and healing. I exercise 3 to 4 times a week (more when it is not summer) and I watch what I eat. I am still fat. What are you telling me here that is new? That will improve my life beyond what I am currently doing?

Secondly how do you respond to recent scientific studies that say weight loss actually increases mortality? No, its not crazies in the fat acceptance movement but actually "non-invested" scientists. Because most people even when they hear coded calls to diet (like you seem to be giving here) create unrealistic goals and start forbidding foods only to lose, gain, regain themselves into some serious problems.

I do not consider myself someone who is against body change through diet and exercise. BUT I find that HAES is the most sane, moderate way to change ones life.

June 22, 2010 | Unregistered CommenterSamira

Samira: I don't know. I really appreciate your comment a lot, though. I don't know what HAES is, so need to look it up. Sounds interesting, that's for sure.

I'll get back to you.

June 23, 2010 | Registered CommenterNavelgazing Midwife

A lot of women are finding excellent results in health improvement and weight loss with the paleo/primal style of high-fat (saturated and monounsaturated, that is, not polyunsaturated) and medium protein eating. I like such approaches because the emphasis is not on 'dieting' or even on 'exercise', but on eating to satiety (much easier for most people on a high-fat diet) and doing explosive, whole body exercises mixed in with the classic 45 minute light walk after dinner (both several times a week to daily). Also there isn't a focus on the scale, but on fat loss (visceral primarily, then subcutaneous).

The paleo/primal approach tends away from counting calories and obsessing about food beyond 'get lots of healthy fat in and stay away from grains and starches most of the time'. It's refreshing to eat lots of meat and vegetables and not feel like there has to be a big thing of pasta/rice/bread there too. It's also refreshing to do a few pull-ups or squats and take a leisurely walk and watch the fat disappear and muscle definition appear. It is also refreshing to be free of the scale and just enjoy the fact that paleo/primal visibly changes bodies for the better even if your scale-weight doesn't change much or as rapidly as you'd expect.

June 25, 2010 | Unregistered Commentermari

I have to second Samira's suggestion that you look into things like HAES. You typically speak ill of WRM and what you appear to think is her lack of point. Reading more on HAES might actually help you understand her point of view better (http://www.plus-size-pregnancy.org/WhatIsSizeAcceptance.html).

Oh, and FWIW...I think you missed the point of WRM's post entirely. In fact, I think you over-simplified her argument to score easy points of your own. Her point being...
"A simplistic cause-and-effect view of obesity and complications can lead to many dubious conclusions and harmful therapies. Yet researchers and authors continue to conflate correlation and causation in obesity research all the time. "

Is it really all that unreasonable to expect that we treat people for what they are...individuals? Is it all that unreasonable to expect that what might be true for you and your weight issues might not be true for someone else? Isn't oversimplification our problem in birth (Friedman's Curve, etc) to begin with? Isn't it entirely possible that you and WRM have more common ground between you than you admit?

July 11, 2010 | Unregistered CommenterUsuallyfrustrated

I do not think I have *ever* spoken ill of WRM or the Kmom site. I think Kmom is the bomb and has really great, accurate things to say about all aspects of the glucose discussion. Not sure where you think I have said anything negative of her or her site. Critiquing something written is very different than how I feel overall and about the person herself.

I absolutely acknowledge that different people lose weight/gain weight/get healthy/get sick in an infinite number of ways, but when one is pregnant, there isn't a lot of time for experimenting to see which way works best to keep glucoses down. It's often enough, all the experimentation, to see what individual *foods* spike the numbers... much less trying out a range of different "diets" (food choices).

Once again, I *know* that WRM and I have plenty in common. I admire her and her work tremendously.

July 11, 2010 | Registered CommenterNavelgazing Midwife

I have studied science. But I haven't come across the 'fat obstetrics'. Very nice article to share and gain knowledge..Thanks

April 6, 2011 | Unregistered Commenterobstetrician sydney

I want to say on the photos and description about the fat people. I have seen many fat people who don't eat too much but still they are so fat. Depends on body organs. But if the fat is not removed from the body, it starts producing serious diseases like diabetes, blood pressure. The most dangerous disease is Heart attack.

May 3, 2011 | Unregistered Commenterobstetrician sydney

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