Department of Obstetrics & Gynecology
University of Utah
Obesity among women of reproductive age is a major health threat in the United States and contributes to the overall morbidity, mortality and costs associated with overweight and obesity. In the year 2000, 117 billion dollars in health care costs and 300,000 deaths were attributed to obesity (Allison, Fontaine, Manson, Stevens, & VanItallie, 1999; Centers for Disease Control and Prevention). Body mass index (BMI), the most commonly used measure to define obesity, is calculated by dividing a woman’s weight in kilograms by her height in meters squared. The International Obesity Task Force defined overweight and obesity using the following classification of body mass index (BMI, defined as kg/m2): <19 underweight, 19-24.9 normal weight, 25-29.9 overweight, 30- 34.9 class I obesity, 35-39.9 class II obesity, and >40 class III obesity. (International Obesity Task Force, 1998) Using this classification system, over 127 million American adults are overweight (BMI>25), 60 million are obese (BMI>30), and 9 million are severely obese (BMI>40) (American Obesity Association).
For the first time in over twenty years the number of obese women nationwide did not increase; however the majority of adult American women are still overweight or obese (Ogden et al., 2006). In 2003-2004, 62% of women were overweight or obese, 33% were obese, and 7% were severely obese (Ogden et al., 2006). This is significantly higher than the NHANES data from 1988-94, where the rates were 50%, 26%, and 4.0 % respectively (Flegal, Carroll, Kuczmarski, & Johnson, 1998; Flegal, Carroll, Ogden, & Johnson, 2002).
Overweight and obesity have long been known to increase the risk and severity of many chronic diseases including type 2 diabetes mellitus, cardiovascular disease, hypertension and arthritis (Field et al., 2001). Table 1 provides a list of the major morbidities associated with obesity. While this list of health consequence associated with obesity is extensive, the most dire consequence, mortality, is also increased. The Nurses’ Health Study prospectively studied over 116,000 women who were disease free at enrollment for 24 years. All cause and disease specific mortality increased in this population with increasing BMI, even after controlling for age, smoking, family history, menopausal status, activity and alcohol consumption (Hu et al., 2004).
Obese women, when compared to lean women, are more likely to suffer from endometrial cancer, breast cancer, stress urinary incontinence, gall bladder disease and depression (American Obesity Association, 2002). Also, they are less likely to participate in health care maintenance activities, such as mammograms and gynecologic exams, which may delay the identification of disease and may worsen prognosis (Fontaine, Heo, & Allison, 2001).
Table 1 Morbidities Associated with Obesity
|Type II Diabetes||Renal Cancer|
|Cardiovascular Disease||Gallbladder Disease|
|Hypertension||Stress Urinary Incontinence|
|Arthritis||Carpal Tunnel Syndrome|
|Postmenopausal Breast Cancer||Sleep Apnea|
|Gastrointestinal Cancer||Depression and poor QOL|
There has been little attention paid to the complications of obesity in women of reproductive age. While obesity complications of pregnancy have been studied, significantly less attention has been paid to postpartum and longterm complications in these women. (The paucity of research during the puerperium is not limited to obese women.) National studies which identify trends in body mass indices, including the National Health and Nutrition Examination Survey (NHANES) and the Behavioral Risk Factor Surveillance System specifically exclude pregnant women from their analyses (Flegal et al., 2002; Freedman, Khan, Serdula, Galuska, & Dietz, 2002). Several studies have shown that obese pregnant women are at increased risk for adverse pregnancy outcomes including gestational diabetes, pre-eclampsia, macrosomia, fetal anomalies, intrauterine fetal demise, early neonatal death, induction, cesarean delivery, postpartum hemorrhage, and infection (Cnattingius, Bergstrom, Lipworth, & Kramer, 1998; Ehrenberg, Dierker, Milluzzi, & Mercer, 2002; Jensen et al., 2003; Lu et al., 2001; Sebire et al., 2001; Watkins, Rasmussen, Honein, Botto, & Moore, 2003).
To explore the impact of overweight and obesity during pregnancy in Utah, birth certificate data from 1991 to 2001 were analyzed. Maternal obesity, as defined by the proportion of women with a BMI greater than 30 at delivery has increased nearly 40% over this past decade in Utah (D.Y. LaCoursiere, Bloebaum, Duncan, & Varner, 2004). (See figure 1). A similar increase in the percent of women who were overweight (BMI >25) or obese (BMI >30) prior to pregnancy has also been identified (D.Y. LaCoursiere et al., 2004). In 2001, 40.2% of women were overweight or obese before delivery. The attributable fraction of cesarean delivery in the overweight and obese was 0.388 (95% CI: 0.369 – 0.407) (D. Y. LaCoursiere, Bloebaum, Duncan, & Varner, 2005). This means that after controlling for other factors, nearly 40% of cesarean deliveries in the overweight and obese are due to increased maternal weight. Statewide, among all women having a cesarean in 2001, 1 in 7 is attributable to overweight and obesity. Cesarean delivery rates are shown in figure 2 for women with and without risk factors of diabetes and hypertension. Increases in preeclampsia have also been seen with the rise in maternal overweight and obesity over this same decade (see figure 3). While much of the above information reflects poor outcomes associated with a woman’s weight before pregnancy, excess maternal weight gain during pregnancy also increases the risk of adverse outcomes. The chance of Cesarean delivery, preeclampsia and birth weight over 4000 grams all increase with excessive maternal weight gain in pregnancy. 22 In fact, 40% of women who gain over 35 lbs during their pregnancy are delivered by primary Cesarean delivery (see figure 4).
Utah data have also been used to investigate the association between obesity and postpartum depressive symptoms. To do so we explored the Pregnancy Risk Assessment Monitoring System (PRAMS), a project sponsored by the Centers for Disease Control and Prevention (CDC). PRAMS is a population-based survey of maternal attitudes and experience from preconception through the postpartum period. (Centers for Disease Control and Prevention). The Utah Department of Health (UDOH) participates in this project. One of the questions pertains to the woman’s postpartum mood. She is asked “In the months after your delivery, would you say that you were- Not depressed at all, A little depressed, Moderately depressed, Very Depressed, Very depressed and had to get help?” The response to this question and questions pertaining to stressors were stratified by prepregnancy body mass index. There were 3,439 women included in the analysis. Among overweight and obese women, there was a trend toward more partner associated stress (p=0.057) and they were more likely to report emotional (p<0.001) and traumatic stress (p<0.001). When stratified by BMI categories, the prevalence of moderate or greater depressive symptoms increases at the extremes of BMI (figure 4). After controlling for marital status and income, prepregnancy obesity (BMI≥30) was associated with greater than moderate postpartum depressive symptoms (adjusted odds ratio 1.53 [95% CI:1.15 – 2.02]) (D. Y. Lacoursiere, Baksh, Bloebaum, & Varner, 2006). While limited in its evaluation of depressive symptoms, this database supports the possibility that obese women could be at greater risk for maternal stressors and postpartum depression. Currently a larger prospective study, funded by the National Institutes of Health, is being conducted in our state.
There have been recent studies presenting interesting information on obesity and breast feeding (Oddy et al., 2006) (Li et al., 2005). Increased prepregnancy BMI is associated with shorter breastfeeding duration (Oddy et al., 2006). Maternal obesity and short duration of breast feeding are additive risk factors for childhood overweight (Li et al., 2005). Recently, biologic data support this epidemiologic association between obesity and short duration of breastfeeding. Increased prepregnancy BMI predicts a lower prolactin response to suckling at 48 hours. Prolactin is responsible for stimulating milk production and thus a decrease in responsiveness could lead to a diminished ability to make milk and perhaps contribute to breastfeeding discontinuation (Rasmussen & Kjolhede, 2004). These studies lead to the possibility that an intervention to improve prepregnancy BMI and or maternal weight gain might improve a woman’s ability to breastfeed.
Overweight and obesity significantly impact women’s health. It affects two-thirds of all women nationwide. . Rates of overweight and obesity during pregnancy are increasing in Utah. Data from our state suggest that it is likewise influencing women’s reproductive health outcomes. Overweight and obese Utah women are more likely to have gestational diabetes, preeclampsia, Cesarean delivery postpartum depression and large babies. Information also supports that overweight and obese women have more difficulty continuing to breastfeed. Maternal weight during pregnancy not only effects the woman’s outcome, but also that of her child. While information is needed to prevent the untoward effects of increased BMI in women, even more data are necessary on primary prevention of obesity.
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