Stemming the Obesity Epidemic

LYNNE JETER

Subhead: SLU Department Chair develops Missouri’s first special obstetrics program

Managing obese pregnant women is a specialty for Raul Artal, MD, and his colleagues at Saint Louis University (SLU), who made headlines two years ago for disagreeing with recommendations by the Institute of Medicine (IOM) for obese women to gain more weight than he believes is necessary during pregnancy.

A Special Class

Many St. Louis area providers refer pregnant patients with a Body Mass Index (BMI) of 45 or greater to the SLUCare Pregnancy Bariatric Clinic. The initial consultation involves a fitness test in the clinic’s exercise laboratory, which includes body composition equipment that measures the body fat content, exercise equipment for stress tests, fetal heart monitors and equipment that measures cardiovascular and lung functions.

Using the information from tests, the program’s exercise physiologist creates a personalized activity plan, which is monitored and evaluated throughout the pregnancy. Also, the program’s dietician helps the patient set realistic goals that frequently include losing weight.

“Women listen to you when they’re pregnant because they want to give their babies the best possible start,” said Raul Artal, MD, medical director of the SLUCare Pregnancy Bariatric Clinic at St. Mary’s Health Center. “They often are most motivated to add physical activity into their routine and to eat a more nutritious diet because they understand their added responsibility for developing their baby.”

 

Artal, chair of the department of obstetrics, gynecology and women’s health at SLU, and medical director of the SLUCare Pregnancy Bariatric Clinic at St. Mary’s Health Center, didn’t endorse the recommendations of the non-governmental, independent, nonprofit IOM organization. Instead, he wrote a bold and well-accepted commentary for Obstetrics & Gynecology, the official publication of the American College of Obstetricians and Gynecologists better known as “The Green Journal,” that disputed the advice by IOM that is designed to improve public health.

“We have a disagreement with the IOM recommendations for gestational weight gain, which in 2009 were virtually identical to those published in 1990 with one exception: obese women are now recommended to gain 11 to 20 pounds compared to the previous recommendations of at least 15 pounds,” said Artal, who also is director of obstetrics and gynecology for SSM St. Mary's Health Center. “Recommending a single standard of weight gain for all obese classes is of concern since higher BMI levels are associated with more severe medical conditions and have long-term adverse health implications.”

Artal, who developed the state’s first special obstetrics program to help stem the obesity epidemic, recommends that obese pregnant women eat a nutrient-rich diet of 2,000 to 2,500 calories daily, which would prompt a weight gain cap of 10 pounds, and in some cases, weight loss.

“I’m doing in my practice what I preach,” said Artal. “We’ve learned over the years that particularly morbidly obese women who maintain or lose weight during pregnancy have better outcomes. Most of them get diabetes, and by maintaining a lower caloric intake and some kind of physical activity—walking at least half an hour a day and preferably half an hour after each meal—they can cut their risk to develop gestational diabetes by about half or more. They also carry a risk to develop preeclampsia. And, obese pregnant women tend to have offspring that’s much larger than the normal population. So by going on this regimen, their babies grow to normal sizes rather than larger sizes, which translates to better benefits for both the mother and the baby.”

Another reason Artal developed the unique program: More than half of obese pregnant women require C-sections because their babies are so large.

“Even though these babies are larger in size, if the mother is affected by diabetes, the babies have delayed organ maturation, specifically lung and liver maturation, and may have significant breathing problems,” he said. “It leads to other complications, such as jaundice.”

Because pregnancy is a unique time for behavior modification, Artal developed a strategy for SLU based on extensive research and experience to manage obese gestational patients in a way to reduce the risk of typical complications from obesity.

“We help these women lose weight during pregnancy, which is safe if done under the close supervision of a knowledgeable doctor,” he said. “We encourage pregnant women to live a normal life, and obese pregnant moms-to-be should look at this as an opportunity to change their lifestyle, and they’ll benefit short and long-term.”

Artal emphasized it’s vital to address the obesity epidemic now in Missouri, which is the nation’s 11th fattest state. Roughly 40 percent of Missourians are morbidly obese, he added. It’s a trend that follows the “Fat Belt” along the Mississippi River, noting that states bordering the river are even higher on the “most obese” list. (Mississippi, Alabama, Louisiana, and Tennessee are among the top five most obese states, according to the 2011 annual report from the Trust for America's Health and the Robert Wood Johnson Foundation.)

“From Chicago to New Orleans, people have a diet in the rich French tradition,” explained Artal. “It’s very rich food with lots of butter and fat, and the population along the Mississippi River has a prevalence of obesity of higher than 50 percent. It’s vital to address the obesity problem at the gestational level because large babies typically result in obese children, and therefore obese pregnant teenagers, increasing the cycle of obesity.”

Artal has noticed that more women are having bariatric surgery prior to pregnancy to lose weight and get in better shape.

“They do much better addressing the obesity problem before pregnancy,” he said. “For one reason, it’s well known that obese women have increased fertility problems. After bariatric surgery and weight loss, they become more fertile. Also, women who go through bariatric surgery have lower risk of gestational diabetes.”