Too much? Too little? Don't worry about it!
One of the biggest stressors for pregnant women is weight gain. Many women receive little, if any, specific nutritional counseling prior to pregnancy. Few obstetric practices spend much time discussing nutrition in pregnancy, while most focus on weigh-ins at each visit, and discussion of whether you are gaining too much or too little weight.
Compounding this problem are the health agencies that also focus on weight gain in pregnancy. Many of my clients are also clients of WIC. One woman, Bridget, had a frustrating experience with WIC.
Bridget was a big woman, nearly six feet tall, and very overweight. As part of my midwifery practice, I spend a lot of time in early pregnancy focusing on nutrition. All clients are asked to keep a food diary for three days prior to nutritional counseling. Each woman is to write down everything that goes into her mouth. We then use this information to look for things she may be lacking in her typical nutrition, and to discuss pregnancy nutrition needs.
The best thing I can say about Bridget’s food diary is that she was honest. Six cans of Pepsi per day was her average. She ate a large pepperoni pizza by herself. Double Whoppers and fries were her mid-afternoon snack. . .you get the picture. Rather than focusing on what she was doing wrong, we looked at what her baby’s needs were for optimal growth. Fresh fruits, vegetables, whole grains, whole food proteins–we discussed the nutrients her baby would get from each of these food groups. Bridget had had a difficult first pregnancy, and was very motivated to have a better experience this time around. I did not criticize or judge Bridget, but encouraged her to consider ways she could add nutrient-packed foods to her current diet.
I was amazed when Bridget stepped on the scale at her prenatal visit the following month. She had lost seven pounds! I questioned her: “Have you been throwing up? Too sick to eat? Restricting your food portions in order to lose weight?”
Bridget grinned. “Nope. I’m feeling great and eating plenty of all the foods on the list you gave me. I just quit eating pizza and cut out the soda.” She handed me a list of the foods she’d eaten over the last three days, and it was wonderful! Everything on her list was a food packed with nutrition. I complimented her on her efforts.
A few days later, Bridget showed up at my office unannounced. “Look at this!” she said, thrusting a paper at me. It was a form letter from WIC, stating that since she had lost weight, she was “at risk” for many complications of pregnancy, and needed to see her provider as soon as possible. “I don’t understand this!” Bridget complained. “I told them what I am eating, and the woman said that my food choices were all really good, but that I couldn’t lose weight during pregnancy. She said I was getting enough calories, but needed to be gaining weight, not losing. I asked her how I could gain weight when I’m already eating as much as I want, and I’m getting enough calories. She couldn’t answer me or tell me what I need to do to gain weight.”
I reassured Bridget that she did NOT need to worry about gaining weight, but should focus instead on eating a wide variety of nutrient-packed foods. I told Bridget that she was doing fine, the baby was growing, and not to worry about the scale.
Bridget continued to lose weight until the last two months of pregnancy, when she finally hit a plateau and then gained three or four pounds. The day after her baby was born, she weighed thirty pounds less than her initial pregnancy weight.
Recent research indicates that obese women can safely go through pregnancy without gaining weight.¹ Although the Institute of Medicine still recommends a small weight gain for obese women, research does not support the theory that weight gain is necessary. Rather, focus should be placed on what the woman is eating instead of how much she weighs. My experience has been that many overweight women start eating better during pregnancy, because they want to give their baby optimal nutrition. This change in diet leads to weight loss, even though the woman is eating adequate calories and a wide variety of healthy foods. I do not consider this weight loss a cause for alarm.
Conversely, underweight women have been encouraged to gain larger amounts of weight during pregnancy. Some find this difficult and become frustrated when they weigh in on the low side at visit after visit. Again, I do not become alarmed in this situation, but instead discuss what the woman is eating. If she is getting adequate calories and nutrition, and her baby is obviously growing normally (based on fundal height measurements), I don’t stress out about low weight gain.
Then there are the women who have an average weight gain, but rather than gaining a steady one pound per week, as many providers recommend, they have gained nothing at one visit, and four pounds at the next, and so on. Many of my clients have complained that past providers criticized their weight gain patterns at every visit, leaving them feeling frustrated, inadequate, and fearful for their baby’s well-being. Some have felt so traumatized that they refuse to step on the scale. Yet this is the pattern I see most often in women–several pounds gained at one visit, fewer pounds at the next, but a normal amount of weight gain overall.
It is vitally important for women to understand what constitutes good nutrition in pregnancy. There is a wealth of useful information on the internet. Some of my favorites are:
http://www.skinnybitch.net/bun/index.html (warning: you may find their language offensive, but the nutritional information is top-quality)
http://pcrm.org/health/veginfo/vsk/pregnancy.html (vegetarian diet, but excellent nutritional information for every pregnant woman)
http://www.drbrewerpregnancydiet.com/id26.html (The Farm diet, inspired by Ina May Gaskin. They reduced incidence of pre-eclampsia to almost nil, and credit their diet during pregnancy)
http://www.wholefoodsmarket.com/nutrition/nutrition-pregnant-moms.php
You will notice that all of these sites focus on whole foods, which are the key to healthy weight gain and avoiding gestational diabetes. Our society exists on refined foods, and the effect is evident in the poor health of so many people.
These nutritional recommendations are given for the vast majority of women who will have normal pregnancies. Red flags that should alert you to talk to your provider about your weight:
- You are experiencing morning sickness to a degree that you are not able to eat or to hold down much food, and this has been going on for more than twenty-four hours.
- Your baby’s growth, estimated by fundal height measurements, is much greater or much less than expected for your dates, for at least two consecutive measurements performed by the same person. This does not necessarily indicate a problem, but should be evaluated.
Common sense tip for today: Focus on what you eat, not what you weigh. Your body will gain the perfect amount of weight to grow the perfect size baby for you. Weight that is gained through healthful eating is more easily lost after birth.
1. Web MD. Pregnancy: no weight gain for obese women? Retrieved 3/15/10 from: http://www.webmd.com/baby/news/20090602/pregnancy-no-weight-gain-for-obese-women
Ugh… I normally really like your site, but the Brewer Diet is one of those points of contention for me. There are two issues I take here: 1. whether Brewer is a safe enough modification to make it a good general recommendation and 2. whether the Brewer Diet prevents pre-eclampsia.
Let’s assume it works the way it say it does: it’s still an intervention, is not going to be appropriate for everyone, and can cause other issues. I know this is anecdotal, but it’s my experience and it’s been rather interesting for me to see. My first two babies were upper 7 lbs, lower 8s on a normal diet with normal weight gain. I switched to the Brewer Diet for my next two pregnancies. Pregnancy 3 I was more lax with later on in the game, but was exceptionally diligent with in the 1st trimester in terms of protein intake in particular. I wound up with a 10 lb 2 oz baby with a 3 minute dystocia and 1 minute Apgar of 0. My home birth midwife figured I must have somehow had undiagnosed GDM, so the next pregnancy I was extremely strict in terms of avoiding sugars and having lots of proteins and whole foods. I passed my glucose challenge by a wide margin, and still had an 11 lber who also had a dystocia. Both of my Brewer pregnancies I was already 3-4cm up on fundal height even at 18 weeks without polyhydramnios, up to a 46cm fundal height at delivery with my 4th child.
Fast forward to this current pregnancy, where I ditched the Brewer Diet and tried to eat normally, going for good quality carbs instead of protein intakes in the 80-100 grams of protein range. I’m 34 weeks with a 33cm fundal height and have been within normal limits the entire time. And I’m nowhere near flirting with pre-e. We’ll see what happens birth weight wise in the coming weeks, but I’m quite optimistic at this point. Let’s assume Brewer does what it says it does and enhances placental growth. There are some animal studies indicating that placental overgrowth can precede fetal overgrowth, and it makes sense that something similar could happen with the Brewer Diet in women already predisposed to grow placentas very well for whatever reason. If that is the case, following the Brewer Diet could cause macrosomia in infants who otherwise would not be macrosomic.
I am not an expert in pre-eclampsia, but I know that the forums over at preeclampsia.org are very anti-Brewer Diet with many members having followed the diet and gotten pre-e or even eclampsia or HELLP. They’ve got a ton of really really good information. Their website is down right now for maintenance but will be up later today (according to their FB fan page.) They have no incentive for being negative about Brewer if it works, given how much they have invested in not getting pre-e. They’re the ones whose lives and health is at risk if they get pre-e again, and they’d probably stand on their heads for the entire pregnancy if it could be shown that such an action would keep them from getting pre-e.
I understand that I’m in the minority of the natural birth community in terms of being strongly anti-Brewer, but I just do not agree with throwing the Brewer Diet up as a general recommendation and especially not as a preventative against pre-eclampsia. I’d ask you to reconsider your statements on those points, and apologize for the novel length reply.
I think you’ve made some very good points here, and I appreciate your comments. You stated:
There are two issues I take here:
1. whether Brewer is a safe enough modification to make it a good general recommendation and
2. whether the Brewer Diet prevents pre-eclampsia.
Let’s assume it works the way it say it does: it’s still an intervention, is not going to be appropriate for everyone, and can cause other issues.
The link that I listed is not to the standard Brewer diet, but a modification of that diet, as used on The Farm (where Ina May Gaskin lives). I did not intend to imply that the Brewer diet or this modification are ones that I think everyone should adopt. I believe women should eat according to hunger, from a wide variety of healthy, whole foods. My intention in providing several links to pregnancy nutrition pages was to give an idea of what healthy whole foods are. It is an unfortunate fact that our society as a whole is often ignorant of what good nutrition is, and physicians rarely have much education in nutrition.
As far as association with pre-eclampsia prevention, I was referring to the following study in making that statement:
Carter J, Furman T, Hutcheson HR. Preeclampsia and Reproductive Performance in a Community of Vegans. Southern Medical Journal. June 1987. Retrieved 03/15/2010 from:
http://journals.lww.com/smajournalonline/Abstract/1987/06000/Preeclampsia_and_Reproductive_Performance_in_a.7.aspx
Of course, one study alone does not allow us to conclude that this diet is for everyone, but I thought the results of this study were interesting enough to warrant mention.
I have never recommended that women adopt the standard Brewer diet, as I agree with you–in my experience it tends to grow very large babies. It is very high in protein and calories, and some women have difficulty forcing themselves to eat that much food.
But the foods that they recommend are healthy food choices, which women can use to develop their own healthy nutrition plan.
I am in my 2nd pregnancy. During my first, I was significantly overweight when I got pregnant. I lost 50 lbs during my pregnancy, mostly due to nausea and not eating as much. When I started eating again I was eating a more healthy diet/amount than I did before I got pregnant. My doctors were not concerned at all about the weight loss because I had it to lose. They did one extra ultrasound in my late 2nd trimester to make sure baby was growing right, and he was. This pregnancy, I started overweight again. I lost 10 lbs in the beginning because I was throwing up so much. Since then? I have gained about 2 lbs. I’m now 32 weeks pregnant, and I can FEEL how much healthier I am this time around. People tell me how great I look, and I’m not at all concerned about my weight. The baby is getting bigger, believe me, I can feel that! People get so obsessed with their weight and I agree that they should just focus on being healthy and passing good stuff on to the baby.
I have a different perspective on the weight gain recommendations for obese women. I understand what you’re saying about nutrition intake changes for obese women sometimes leading to safe weight loss during pregnancy. However, many of us aren’t obese because we eat like Bridget did before her pregnancy – some people are just naturally fat, just as some are naturally thin. (Aside: I try to be honest when describing myself as fat. It is a word that means the opposite of thin – and that’s all it means. It’s not a judgment or any self-deprecation, merely a descriptor.) I’ve read some heartbreaking stories (read Well-Rounded Mama for examples) of obese women who gained what would otherwise be a normal amount of weight during pregnancy but were berated because they gained “too much” relative to their pre-pregnancy weight. I agree with you entirely that it should be about the diet, not the weight, but it seems like care providers are more willing to go with that statement when an obese pregnant woman with a healthy diet gains less weight rather than more.
Good point; you are absolutely right. I think it is just as important to focus on what a thin pregnant woman eats, or an average-weight pregnant woman eats. Whether a woman with a higher-than-average BMI gains or loses, I don’t stress as long as she is eating well.
There are more concerns for women with high BMIs who also gain excessive amounts of weight; these are related to increased pregnancy complications, but I don’t think either of us were referring to those types of situations here. Thank you for pointing this out.
Man, I wish I’d had this information previously (plus the ability to have more indepth discussion about it). My metabolism stinks and is soooo slow. When not pregnant I only need/want around 1000 calories a day. In the first trimester of both my pregnancies I lost around 20-25 lbs before I managed to increase my food intake to 2000 calories a day, my stomach was only hungry for half that (had it to spare because a previous medication made me gain 50lbs). I ended up adding ‘junk’ foods to my diet (most of which I rarely eat under normal circumstances) just to get the calories in because it was so hard to double my foot intake. Now with my second pregnancy I ended up with gestational diabeties late in the pregnancy (in my doctor’s words ‘exceptionally well controlled’ via diet) but trying to stick to the diabetics diet AND get enough calories has been impossible, I’ve lost weight since 34 weeks (38+ right now) and ’spilled’ ketones so much I was told to stop bother testing, and have been worried sick about it! Finally this last week I’ve stopped losing weight, but only by adding in a great deal of extra protein (and some small servings of ice cream that falls within my carb count but are high calorie), and I’m worried about the extra protein making baby too big. My first baby was 9lbs 1oz and was a 5 min shoulder dystocia with a 1 min apgar of 0. I really wish OBs would give better calorie/weight gain/diet advice to those of us who fall outside the norm!
I am currently 40 weeks pregnant with my first, I started out overweight but I did lose weight in the beginning. My doctors have never said anything about my weight either way. At my first appointment in pamphlets and papers they hand out that anyone wanting to speak to a nutritionist only had to tell their doctor and they would refer them. It also gave a sample of foods to try to eat during pregnancy such as fresh produce and whole grains.
I think there are enough worries during pregnancy that OB’s do not need to put pressure on women about weight gain or loss as well. It is one thing if an OB truly is worried about a pregnant woman’s weight gain or loss and want to make sure they are getting enough nutrients but they should not give their patients a hard time. We feel insecure enough that bullying us into doing their will is not a great idea.
What would you recommend to a woman who is losing weight because of morning sickness? In both my pregnancies, I lost about 10 lbs during the first trimester (starting at 120-130 lbs) because I was throwing up so much and eating so littler. I used medication (metoclopramide) to help me be able to eat a little, but I was still throwing up at least once or twice a day. However, both my babies were healthy and normal weights (7 1/2 lbs) and I gained weight fine after the first trimester was over. Would you suggest a different medication or another remedy? Is weight loss like that inherently dangerous or does it depend on the woman and her ‘normal’?
It’s important to differentiate between weight loss in pregnancy while eating a healthy diet, and weight loss because you are so nauseated you can’t hold down food or liquids. The first is nothing to worry about, but the second can be dangerous, primarily to the mother.
In early pregnancy, the baby’s needs for calories are minimal. However, the mother can be so sick she cannot hold down food or enough liquids to maintain normal body functioning (this is termed hyperemesis gravidarum). While most women have some morning sickness, feel nauseated most of the time, and vomit occasionally, a few will be so sick they lose more than 5% of their body weight. So for you, starting out at 120 pounds, intervention should begin if you lose more than 6 pounds because of vomiting.
Hyperemesis can also cause changes in electrolyte levels in the body, which potentially could cause heart irregularities and other problems. Women who are this severely affected must be hospitalized for IV feedings and electrolytes, and are often given steroids along with medication to quell the nausea.
Some women who have severe morning sickness may also be infected with H. pylori, which is associated with certain types of ulcers, but can also trigger severe nausea without the woman having an ulcer.
Women who are having severe nausea and vomiting need to be closely monitored for excessive weight loss, electrolyte imbalances and dehydration.
While metaclopromide (Reglan) is a common treatment for morning sickness, other remedies include Unisom, Vitamin B12, ginger root capsules or ginger tea, phenergan, and sea bands (acupressure wrist bands that fishermen wear to prevent seasickness). The medication I have found to work the best for frequent vomiting, however, is ondansetron (Zofran), a lozenge you dissolve under your tongue. It is frequently given to chemotherapy patients to minimize the nausea associated with treatment. Most insurances will cover it, but it is very expensive to pay for out-of-pocket.