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Maternal Obesity
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Book description

Afflicting more than 300 million women across the globe, obesity has profound effects on health during pregnancy and on the wellbeing of the unborn child. In the face of such a challenging pandemic, this book reviews the latest research and provides up-to-date advice on clinical management. Maternal Obesity addresses the adverse effects of obesity among women of childbearing age, including infertility, medical complications, problems in labor, and adverse birth outcomes, and it reviews evidence that the obese mother's in utero environment has long-lasting influences on the health of the developing child. Chapters cover basic, clinical, and population perspectives, providing a range of valuable information from mechanistic insight through to public health and policy implications. Invaluable for obstetricians, gynaecologists, paediatricians, general and family physicians, subspecialists in obstetric and paediatric medicine, midwives, and dietitians, as well as researchers and public health policy makers seeking to tackle the burden of maternal obesity-related illness.

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Contents

  • Section 1 - Trends and determinants of obesity in women of reproductive age
  • View abstract

    Summary

    The global nature of the obesity epidemic was officially recognized by the WHO in the late 1990s. The global obesity pandemic is increasing at an alarming rate in both developed and developing countries and is considered one of the most important public health challenges of the twenty-first century. In most developing countries, the prevalence of obesity is lower in rural compared to urban areas. The problem of obesity in developing nations is dramatic not only due to population size, but also to the proportionally smaller investments in public health programs in many of these countries. Although the increasing prevalence of obesity among women of childbearing age is part of the larger worldwide epidemic, its consequences can be particularly devastating. In contrast to malnutrition and infectious diseases, which have always dominated the attention of public health specialists and organizations, the causes and consequences of obesity have only recently achieved global recognition.
  • 2 - Determinants of obesity
    pp 8-19
  • View abstract

    Summary

    Obesity has become a global epidemic. This chapter provides an overview of major risk factors of obesity, including those that are specifically relevant to women of reproductive age. Available data support the roles of unhealthful food choices, a sedentary lifestyle, and inadequate sleep duration in the occurrence of weight gain and obesity. Child bearing related factors such as parity, lactation, breastfeeding, gestational weight gain, and postpartum weight retention also play an important role in long-term weight gain among women. The etiology of obesity also has a genetic component. Research is needed in the most effective ways to prevent weight gain through improving diet and lifestyle, and promoting breastfeeding among women of reproductive age, including individual behavioral changes and creation of a supportive social environment. Minimizing gestational weight gain and reducing weight retention after pregnancy appear to be attractive public health interventions to reduce weight gain or obesity for women.
  • 3 - Obesity and fertility
    pp 20-34
  • View abstract

    Summary

    The role of body weight on human reproductive function and fertility has received considerable attention in the medical literature. Time-to-pregnancy studies are very useful in determining the overall effects of any exposure on overall fertility. Studying the role of overweight and obesity among couples undergoing assisted reproductive technology (ART) can serve multiple purposes. First, it provides clinically useful information addressing the specific needs of infertile couples. Second, ART provides a unique opportunity to study the role of obesity on reproductive physiology and pathology. Obesity leads to a wide range of systemic alterations including changes in circulating levels of adipokines, reproductive hormones, markers of endothelial dysfunction, and systemic inflammation, as well as metabolic disturbances in lipoprotein metabolism, glycemic control, and increased insulin resistance. The existing evidence on whether clinical management of obesity has any effects on fertility is mostly limited to women with polycystic ovary syndrome (PCOS).
  • Section 2 - Pregnancy outcome
  • View abstract

    Summary

    Obesity is a strong determinant of obstetric morbidity and mortality. This chapter summarizes the current state of knowledge of the relationship between obesity and adverse maternal outcome, including effects on the health of the pregnant mother as well as complications at the time of delivery. Total body fat can be measured by direct methods such as dual energy X-ray absorptiometry (DEXA) and magnetic resonance imaging (MRI). Maternal obesity is overrepresented in maternal deaths in developed countries. Obese pregnant women have an increased incidence of labor induction. The evidence shows a marked increased risk of adverse obstetric events in obese pregnancies, including gestational diabetes, hypertensive diseases, thromboembolism, infection, cesarean section, and postpartum hemorrhage. There are also clear indications that risks increase as body mass index (BMI), or the levels of obesity, increase. In most developed countries the prevalence of obesity is around 20%.
  • 5 - Potential mechanisms contributing to gestational diabetes and pre-eclampsia in the obese woman
    pp 45-55
  • View abstract

    Summary

    This chapter discusses potential mechanisms linking obesity to gestational diabetes mellitus (GDM) and pre-eclampsia (PE). The molecular mechanisms leading to excess hepatic fat accumulation remain elusive. In pregnancy, maternal fat metabolism is of increasing importance as gestation advances in order to spare carbohydrate for the fetus. There is a well-described association between PE and subsequent cardiovascular disease (CVD) risk, especially for those women with a history of early severe PE. Substantial weight loss via bariatric surgery can considerably lessen the risk of PE as demonstrated in a recent retrospective analysis in which risk for PE or eclampsia was 80% lower in the same women after surgery. Lifestyle interventions in obese pregnant women may also prove effective. Successful placentation is essential for healthy pregnancy outcome, and in PE partial failure of trophoblast invasion is likely to play a major role in the disease process.
  • 6 - Fetal and infant outcomes in obese pregnant women
    pp 56-69
  • View abstract

    Summary

    Maternal obesity has a significant impact on the risk of fetal and neonatal mortality, and on the development of congenital anomaly, at both individual and population level. This chapter summarizes the available epidemiological evidence, and discusses potential explanations and public health implications. A number of epidemiologic studies have explored the relationship between maternal body mass index (BMI) in early pregnancy and the risk of stillbirth. The impact of maternal obesity on adverse fetal and infant outcomes depends on both rates of obesity, and of adverse pregnancy outcome, in the population in question. Obesity has a complex relationship with socioeconomic status, with higher BMI in women typically correlating with deprivation in developed countries but with wealth in less developed countries. Clinical studies are required to develop and evaluate effective behavioral interventions to reduce weight in women both pre- and post-pregnancy.
  • 7 - Obesity in pregnancy and mental health
    pp 70-80
  • View abstract

    Summary

    Pregnant women with mental disorders are more likely to be obese than pregnant women without mental disorders. This chapter reviews the evidence on how obesity in pregnancy is related to mental disorders and the implications of this for the management of obesity in pregnancy. Common mental disorders include depressive disorders and anxiety disorders. Binge eating disorder was included in the American Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) as a provisional eating disorder. Clinical studies have found that women being treated for bipolar disorder are at increased risk of eating disorders. Structured cognitive behavioral therapy programs are well-established treatments for binge eating disorder, but while these typically reduce bingeing behavior, they appear less effective at reducing weight. Moderate physical activity and nutritional advice are recommended for pregnant obese women and could therefore indirectly improve mental health as well as physical health.
  • Section 3 - Long-term consequences
  • View abstract

    Summary

    This chapter focuses on the evidence for the association between gestational weight gain and postpartum weight retention among obese women, as well as the association between obesity and lack of breastfeeding, and how these associations are potentially interrelated to cause further disease in obese women. Overweight and obese women are less likely to initiate breastfeeding and more likely to prematurely stop breastfeeding compared to their normal weight counterparts. There is currently little investigation of the interrelationships between obesity, pregnancy, and chronic disease. Risks of hypertensive disorders are highest among obese women who maintained or increased their BMI between pregnancies. Maternal obesity is also associated with later development of type 2 diabetes mellitus (T2DM/pre-T2DM) and heart disease (CHD)/pre-CHD. The current literature suggests that maternal obesity has many long-term health consequences for the mother; however, the degree to which pregnancy contributes to these outcomes is uncertain.
  • 9 - Long-term consequences of maternal obesity and gestational weight gain for offspring obesity and cardiovascular risk: intrauterine or shared familial mechanisms?
    pp 87-99
  • View abstract

    Summary

    Cardiovascular disease (CVD) is a leading cause of death in low-, middle- and high-income countries, accounting for a quarter of deaths globally. This chapter examines what is currently known about maternal adiposity and gestational weight gain (GWG) and their associations with long-term of spring health, focusing on obesity and cardiovascular risk factors in offspring. It begins by summarizing the potential mechanisms that could explain the influence of maternal adiposity and GWG on offspring health. In support of the developmental over nutrition hypothesis, high concentrations of maternal glucose among those with gestational diabetes have been shown to increase nutrient transfer to the fetus and result in fetal hyperinsulinemia and increased fetal growth. Existing evidence suggests that intrauterine mechanisms are likely to result in long-term effects on offspring adiposity and cardiovascular risk factors among the extremely obese, in those with diabetes, and in association with greater amounts of GWG.
  • 10 - Influences of maternal obesity on the health of the offspring: a review of animal models
    pp 100-114
  • View abstract

    Summary

    This chapter provides a summary of the role that animal models have played in contributing to our understanding of potential influences of maternal obesity on offspring health in later life. The majority of laboratories interested in addressing transgenerational influences of maternal obesity use rodents, generally rats and mice, which grow to maturity in a few months. There is clear evidence for altered placental transfer of key metabolites from mother to fetus in both altricial rodents and precocial animals in the setting of maternal obesity. Investigation of effects on programming of offspring exercise preferences and metabolic rate would also be of considerable value in determining overall mechanisms that predispose to obesity. Cardiovascular function of the progeny may also be compromised by maternal obesity. The future will also inevitably lead to better understanding of the interaction between the genes and the environment, for which these models are eminently suitable.
  • 11 - Developmental origins of obesity: energy balance pathways – appetite
    pp 115-123
  • View abstract

    Summary

    The perinatal environment exerts profound effects on the structure and function of the mammalian central nervous system. This chapter reviews the wide scope of structural and molecular changes that have been observed in specific brain regions involved in appetite regulation, in particular the hypothalamus, when individuals are exposed to an obesogenic environment during perinatal life. Epidemiological and clinical studies have provided valuable information on the role played by maternal obesity and early postnatal over nutrition in increasing the susceptibility for the development of diseases in adult life, including obesity and diabetes. Animal models have also been useful in identifying organizational and regulatory changes that occur within key systems that are involved in metabolic regulation. They showed that exposure to an obesogenic environment during critical periods of life has lasting effects on the development and organization of hypothalamic circuits that regulate body weight and energy balance.
  • 12 - Adipose tissue development and its potential contribution to later obesity
    pp 124-134
  • View abstract

    Summary

    The early life environment may persistently influence the development of adipose tissue, thereby predisposing the offspring to obesity. This chapter reviews the limited information available, which suggests that the early life nutritional environment can influence adipocyte biology and influence the risk of obesity in later life. The maternal nutritional environment can have a major impact on long-term metabolic health of the offspring. More information from animal models is available in relation to the influence of maternal nutrient restriction in early and mid-gestation in sheep, which also increases glucocorticoid receptor and 11ßHSD1 expression and reduces expression of 11ßHSD2 in ovine perirenal adipose tissue at term, changes that persist up to six months of age. Both animal experiments and human epidemiological data suggest that there is a substantial role for early life experiences in the programming of adipose tissue function and distribution.
  • 13 - Maternal diet and nutritional status and risk of obesity in the child: the role of epigenetic mechanisms
    pp 135-150
  • View abstract

    Summary

    This chapter reviews the maternal obesity literature, which suggests that epigenetic modulation of gene expression is likely to serve as one of the more promiscuous molecular mechanisms with which these maternal and early developmental footprints are cast. A study of epigenetic modifications in the development of obesity is a new and burgeoning field. Using animal models of maternal obesity, changes in fetal phenotype are being characterized. Prader-Willi syndrome is an imprinting disorder, which yields striking evidence for epigenetic mechanisms in the etiology of obesity. Experiments with mice containing the A vy allele have shown direct evidence of alterations in maternal diet leading to increased body weight of the offspring, concomitant with methylation changes in the fetal Agouti promoter. The chapter argues that in accordance with the developmental origins of adult disease hypothesis, perturbations in the in utero environment influence the development of diseases later in life.
  • Section 4 - Interventions
  • View abstract

    Summary

    This chapter reviews and summarizes the primary literature on excessive gestational weight gain (GWG) interventions, including both randomized controlled trials (RCTs) and non-randomized interventions. It includes both categories of studies because many of the earliest and/or commonly cited interventions to limit excessive GWG were not RCTs. To be clinically meaningful, results of interventions must be relevant to specific patient populations in specific settings. Increasingly, obesity experts are suggesting that that a transdisciplinary and multilevel approach is essential for understanding and ultimately preventing obesity. Inclusion and exclusion criteria differed among the various studies. In general, studies that included physical activity as the primary intervention limited enrollment to women who had been sedentary. On the whole, the literature suggests that interventions to improve diet or physical activity during pregnancy or reduce excessive GWG have been moderately successful in doing so but the degree of restriction, if achieved, is generally modest.
  • 15 - Interventional strategies to improve outcome in obese pregnancies: insulin resistance and gestational diabetes
    pp 179-198
  • View abstract

    Summary

    This chapter addresses the metabolic sequelae of maternal obesity, and by detailing effects on glucose, lipid, and protein metabolism, parallels with type 2 diabetes are highlighted. In normal pregnancy, dynamic changes in maternal glucose homeostasis and insulin sensitivity accompany the alterations in lipid and protein metabolism. Pre-existing diabetes and poor maternal glycemic control have classically been associated with adverse pregnancy outcome. Lifestyle intervention is now a critical component of the treatment strategy for diabetes, hypertension, cardiovascular disease, and obesity in non-pregnant patients. Epidemiological studies have suggested that physical activity prior to and during pregnancy may significantly reduce the risk of gestational diabetes. Some preliminary evidence suggests that combining simple maternal demographic and clinical characteristics will allow detection rates similar to those for type 2 diabetes, but external validation is still required. The maternal obesity epidemic has stimulated the need for development of effective interventions to improve pregnancy outcome.
  • 16 - Intervention strategies to improve outcome in obese pregnancies: micronutrients and dietary supplements
    pp 199-208
  • View abstract

    Summary

    This chapter reviews data highlighting the vulnerability of obese women to multiple micronutrient deficiencies. It summarizes the evidence supporting the effectiveness of nutrition interventions at preventing key birth outcomes among obese pregnant women. Increased body mass index (BMI) in non-pregnant women is associated with decreased serum folate, ascorbic acid, vitamin E, total carotenoids, and selenium in a variety of populations. With the poor micronutrient status of obese women of childbearing age, and potentially the same relationship in obese pregnant women, it is critical to understand whether micronutrient interventions could positively impact birth outcomes in obese pregnancy. Several high-quality observational studies of birth defects, pre-eclampsia may provide additional insight into whether micronutrient supplementation may reduce the likelihood of poor outcomes among obese pregnant women. Future rigorous observational studies exploring a wide range of micronutrients and risk of poor outcomes of women with high pre-pregnancy BMIs will add to the evidence base.
  • 17 - Pre-pregnancy bariatric surgery: improved fertility and pregnancy outcome?
    pp 209-222
  • View abstract

    Summary

    This chapter summarizes the most commonly performed bariatric operations. It reviews the impact of pre-pregnancy bariatric surgery on the female reproductive functions and the relevant pregnancy outcome parameters. The chapter formulates recommendations for clinical care of these patients for both the postoperative as well as the prenatal period. Mixing the different types of bariatric surgery might lead to unreliable conclusions since a different outcome can be expected after the restrictive type than after the malabsorptive types. Women experiencing pregnancy after bariatric surgery have important reproductive health care needs. The specific needs of these high-risk pregnancies are best addressed by a multidisciplinary team including obstetricians, surgeons, endocrinologists, pediatricians, psychiatrists, and nutritionists. Some aspects of prenatal care in women with a history of bariatric surgery require specific attention. Pregnancy after surgery improves many pregnancy outcomes but adds new risks related to nutritional deficiencies and surgical complications, thus requiring a specialized multidisciplinary approach.
  • Section 5 - Management and policy
  • View abstract

    Summary

    This chapter summarizes the clinical management of obesity in pregnancy, based on evidence where it exists, and highlights the areas where further research is needed. Obese women who are pregnant are recognized as a high-risk group by both the American College of Obstetricians and Gynecologists (ACOG) and the Royal College of Obstetricians and Gynaecologists (RCOG) and should therefore be referred for appropriate antenatal care. All obese women should receive a dietary assessment and nutritional counseling. Obstetric ultrasound is used widely in the developed world for pregnancy dating, detection of higher order pregnancies and fetal anomaly, and estimation of fetal growth. Obesity is a well-recognised risk factor for gestational diabetes mellitus, and pre-gestational diabetes is more prevalent in obese women. It has long been recognized that hypertensive disorders are more prevalent in the obese population. The anesthetist plays an important role in the care of the obese parturient.
  • 19 - Public health policies relating to obesity in childbearing women
    pp 237-244
  • View abstract

    Summary

    This chapter presents the national public health policies and programs related to helping women to conceive at a healthy weight, gain weight appropriately during pregnancy, and limit weight retention postpartum. Guidance on implementing weight gain guidelines was developed for prenatal care providers after the release of the 1990 Gestational Weight Gain (GWG) Guidelines. The policy framework for healthy weight gain during pregnancy exists and is supported by both expert committee reports and practice guidelines in the US. A postpartum visit was less likely among women with lower use of or access to health care. The Institute of Medicine/National Research Council (IOM/NRC) committee that recently revised the guidelines for GWG made recommendations that, if fully implemented, would represent a radical change in care offered to women of childbearing age, potentially leading to a reduction in obesity among women of childbearing age.

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