Dr Kabukoba’s work has been covered extensively
He has appeared in national media including
The Times, Daily Express and The Daily Telegraph newspapers; on SKY News television and on BBC radio in relation to the innovative work that he has undertaken.
Pregnancy Weight Loss Help: Pregnancy Obesity Care Guidelines
Managing Obesity Before Pregnancy – CMACE/RCOG Joint Guideline
You are advised to get into shape before you conceive.
Dr Mathew Capehorn, Clinical Director, National Obesity Forum and Clinical Manager at the Rotherham Institute for Obesity, reviewed how and why it is important to advise women about weight management before they become pregnant (19th March 2010).
His presentation focused on overcoming challenges to implementing two key guidelines points:
- Primary care services should ensure that all women of childbearing age have the opportunity to optimise their weight before pregnancy. Advice on weight and lifestyle should be given during family planning consultations, and weight, body mass index and waist circumference should be regularly monitored.
- Women of childbearing age with a BMI _30 should receive information and advice about the risks of obesity during pregnancy and childbirth, and be supported to lose weight before conception.
The challenges of calculating BMI in children who become pregnant under the age of 18 was highlighted. If the adult standard formula for calculating BMI {Wt (kg) x height (cm)2} is used it will seriously underestimate the BMI of the young person. It is therefore important to use BMI centile charts for girls. The problem of teenage pregnancy in the UK is well documented 1,2.
There are numerous important reasons why health care for obese pregnant women is important. Pregnancy outcomes among obese is poorer compared to non-obese in many respects:
Maternal and Fetal Risks in obese women with BMI Equal or Greater 30.
Source CMACE/RCOG Joint Guideline Appendix 3.
| Risk of: | Increase compared to women with Normal BMI |
| Diabetes | increased 2.5 – 3.6 times |
| Increased Blood Pressure problems | Increased 2.1 – 3.3. times |
| Deep Vein Thrombosis and Embolism | Increased 9.7 times |
| Slower Progress of Labor | Increased to 7 hours compared to 5 hours |
| Caesarean birth including Emergency | Increased 2 times |
| Postpartum Hemorrhage | Increased 1.4-3 times |
| Wound infection | Increased 2.24 times |
| Birth Defects | Increased 1.6 times |
| Prematurity | Increased 1.2 times |
| Big babies (weighing more than 4.0 kg) | Increased 2.4 -3.1 times |
| Difficult birth due to broad shoulders (dystocia) | Increased 3 times |
| Still birth | Increased 2 times |
| Neonatal Death (baby dying soon after birth) | Increased 2.6 times |
Furthermore, babies born to obese mothers are known to develop a number of chronic childhood diseases including diabetes and obesity.
On the other hand there is good supporting evidence that weight reduction leads to improved pregnancy outcomes including the reduction of diabetes in pregnancy 3, 4.
Supplementation is important:
- Women with a BMI greater than 30 wishing to become pregnant should be advised to take 5mg folic acid supplementation daily, starting at least one month before conception and continuing during the first trimester of pregnancy.
- Health professionals should take particular care to check that women with a booking BMI greater than 30 are following advice to take 10micrograms Vitamin D supplementation daily during pregnancy and while breastfeeding.
Taking pre-conception folic acid is associated with a decrease in the incidence of neurotube defects by up to 72%. 5mg of Folic acid daily is recommended for a couple of months before conception, because obese have been found to have lower folate levels and are at a higher risk of fetal abnormalities. See table above.
My personal view is that women should be advised to take good quality supplements of Vitamin D and B complex for several reasons.
- There is evidence to support the view obese women do not eat healthily, contributing their state of obesity.
- That there is wide spread deficiency of Vitamin D in the population.
- Vitamin B series, particulary folic acid and Vitamin B6, are vital for the metabolism of homocystine, whose metabolic disorders is known to lead to CVD 5,6, 7.
- Even in the absence of genetic predisposition of homocystine metabolic disorders, low folate, Vitamin B12 and B6 could be contributory factors in the pathogenesis of cardiovascular disease, prevalent in obese individuals.
Advising losing weight in pregnancy is challenging because complex nutritional needs of the pregnant woman. It is best to advise on a balanced diet and exercise. Personally, I advise pregnant women to eat healthily in order to maintain weight rather to lose weight. It is unlikely that that a woman who has not been overweight before pregnancy will gain excessive weight to endanger her life or her pregnancy.
Dr Capehorn provided some tips on weight loss in general, and one of the chart is reproduced here.
Energy expenditure for various activities:
| Sitting | 100 kcals/hr |
| Standing | 140 kcals/hr |
| House work | 180 kcals/hr |
| Gardening | 220 kcals/hr |
| Brisk walking – 4 mph | 330 kcals/hr |
| Squash | 600 kcals/hr |
| Jogging - 6 mph | 750 kcals/hr |
The advice to women aspiring to lose weight before, during or after pregnancy is that consistency of activity is far more important that an irregular, one off activity as a means of burning calories.
References for this paper:
1. Zosia Kmietowicz
US and UK are top in teenage pregnancy rates
BMJ. 2002; 324(7350): 1354.
2. Debbie A Lawlor J
Teenage pregnancy rates: high compared with where and when?
R Soc Med 2004;97:121–123
3. Artal R, Lockwood CJ, Brown HL
Obstet Gynecol. 2010;115(1):152-5.
Weight gain recommendations in pregnancy and the obesity epidemic.
4. http://www.iom.edu/Reports/2009/Weight-Gain-During-Pregnancy-Reexamining-the-Guidelines.aspx
5. Strain JJ, Dowey L, Ward M, Pentieva K, McNulty H
Proc Nutr Soc. 2004;63(4):597-603.
B-vitamins, homocysteine metabolism and CVD.
6. McKinley MC
Proc Nutr Soc. 2000;59(2):221-37.
Nutritional aspects and possible pathological mechanisms of hyperhomocysteinaemia: an independent risk factor for vascular disease.
7. Daly S, Cotter A, Molloy AE, Scott J
Semin Vasc Med. 2005 May;5(2):190-200.
Homocysteine and folic acid: implications for pregnancy.
Posted in Blog, Pregnancy Obesity Care Guidelines
Tagged guidelines, managing obesity, obesity pregnancy
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Obesity in Pregnancy Care – Stating the Obvious?
The CMACE/RCOG guidelines make the following recommendations:
“Management of women with obesity in pregnancy should be integrated into all
antenatal clinics, with clear policies and guidelines for care available.”
Stating the obvious?
Although there was no single unified National guideline statement on the management of the obese woman in pregnancy, I cannot think of a UK centre or PCT (Primary Care Trust) that does not have a coordinated approach to managing obesity in pregnancy.
Improved care could not be achieved any other way – without clear policies and guidelines in place for professionals.
Whether this guideline statement is reaffirming what is current practice or there is a significant lack of joint up approach to caring for women with obesity in pregnancy is not clear.
The statement acknowledges that the problem of obesity is going to get worse, as shown below by Heslehurst et al (2007)1
The hypothesis advanced by Catalano (2003) explains individual maternal and fetal obesity, predating childhood obesity which in turn leads to adult obesity (see diagram below)
This is in keeping with Fetal origins of adult disease theory advanced by Prof Barker of Southampton University.
References:
1.
Heslehurst N, Ells LJ, Simpson H et al
Trends in maternal obesity incidence rates, demographic predictors, and health inequalities in 36,821 women over a 15-year period BJOG: In International Journal of Obstetrics and Gynaecology 2007; 114(2):187-94.
http://dx.doi.org/10.1111/j.1471-0528.2006.01180.x
2.
Patrick M. Catalano, M.D
Obesity and Pregnancy—The Propagation of a Viscous Cycle?
The Journal of Clinical Endocrinology & Metabolism 2003; Vol. 88, No. 8 3505-3506
http://jcem.endojournals.org/cgi/content/full/88/8/3505
CMACE/RCOG Joint Guidlines – How They Were Developed
The critically important first step.
Dr Kate Fitzsimons, Research Fellow at CMACE, presented and explained the methodology used to collect, analyze and agree on the validity of the evidence available and come to a consensus.
In order to advise the profession and in order to improve standards of care for obese pregnant women, it is important that the advice provided is reliable and useful.
The way evidence for the management of obese women is put together is critically reliant on the methods and criteria set for searching, examining and accepting that evidence. Scientific evidence is not always available on the matters at hand, or equally valuable and reliable.
Therefore, the expert group had to agree right from the start how they were going to collect the evidence and the criteria on which to grade the value and reliability of the evidence. Those interested into seeing the exact methods employed can go here for details.
Consensus was reached by asking each expert group member to examine available evidence in his or her field of expertise and provide opinion anonymously. Opinions were aggregated and sent back again and again until a concrete view was reached. This method known as the Delphi method is used extensively where solid research evidence is sparse and consensus is only possible based on experience, opinion and merge published evidence out there.
The expert groups included Anesthetists, midwives, a Dietician, Neonatologist, Endocrinologists, Obstetricians, Obstetric physician, General Practitioners, Obstetric physician, Lay representative, Public health physicians, Physiotherapist, a Manual handling expert and an imaging expert. So you can see every possible professional likely to be involved in the clinical care of the obese pregnant woman is represented.
The composition of the expert group is notably London-centric, with most experts drawn from a few centers in the capital. Also notable for their absence are psychologists and lifestyle experts who have key role to play in addressing long term obesity prevention and management.
The first and foremost, the Group had to agree on a method of collecting and assessing the evidence, and where evidence was unavailable collecting consensus professional opinions.
It is highly commendable that in a short period of time, the expert group reviewed 498 standards through 4 stages and came out with 38 implementable standards that form part of the final guidelines published on the 19th March 2010.
Areas that are covered in the guidelines include the following:
1. Pre-pregnancy care
2. Antenatal care provision
3. Measuring weight, height and Body Mass Index
4. Providing information to women
5. Assessing risk during pregnancy
6. Prevention of Deep Vein Thrombosis
7. Maternal health Surveillance and screening
8. Planning labor and delivery
9. Care during childbirth
10. Breastfeeding
11. Follow-up after pregnancy
12. Local adaptation of the guidelines
13. Facilities and equipment
14. Staff education and training
15. Future research
The details of the guidelines will now be summarized a step by step fashion over the coming few weeks.
Sources: http://www.rcog.org.uk/files/rcog-corp/ManagementofWomenwithObesityinPregnancyCMACERCOG.pdf
Posted in Blog, Pregnancy Obesity Care Guidelines
Tagged ante-natal care, Body mass index, breastfeeding, care during childbirth, deep vein thrombosis, delphi method, expert group, management of obesity in pregnancy, obese pregnant women, pre-pregnancy care, pregnancy obesity, pregnancy weight loss, risk assessment during pregnancy
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Management of Women with Obesity in Pregnancy Guidelines launched in London
As expected, guidelines for the management of obese pregnant women were launched at a special event in London. Attended by more than 200 doctors and midwives from across the England and Wales, the conference was opened by Prof James Walker of Leeds. He explained the background to the guidelines, the benefits to women who can now expect much improved and coordinated care than previously available.
Mr Richard Gongdon , Chief Executive of CMACE (Centre for Maternal & Child Enquiries), explained the set up of the group of multidisciplinary experts that worked together over a period of almost one and half years to put together the guidelines that were being launched.
CMACE became a charity in 2009 and was tasked with work that previously was undertaken by CEMACH, focusing on Maternal Death Enquiry, Perinatal Mortality Surveillance, development of Obesity in Pregnancy and Intrapartum Care.
Mr Gongdon went on to explain why the development of the Obesity in Pregnancy Guidelines was an important task for the organization and the nation; Obesity in pregnancy
• Is one of the most important factors in deaths of mothers following childbirth
• Contributes to poor baby outcomes
• Associated with increased pregnancy and labour complications
• The guidelines can be expected to lead to improved outcomes of both mothers and babies.
Professor Ian Greer addressed and explained the problems of obesity in pregnancy. He reiterated the significant contribution obesity makes to the overall pregnancy related deaths. About 52% of mothers dying of clots on the lungs, venous thromboembolism, had BMI of 25 or more. Worryingly, obesity rates in the UK have doubled from under 10% in 1980 to 19% in 2004. Undoubtedly even higher today.
Obesity in pregnancy is a problem that not only concerns obstetricians but many other specialists particularly pediatricians, physicians, anesthetists and midwives. Obese women are more likely to experience miscarriages, have abnormal babies with spina bifida, congenital heart defects and even cleft palate. These risks could be much reduced by pre-pregnancy weight loss and folic acid supplementation.
In fact, the more obese the woman, the higher the risk of spinal and brain defects; exhibiting a very close relationship between obesity and baby defects.
Obesity also affects a pregnant woman’s well being in other ways. The risk of pre-eclampsia in a woman with a BMI of 35 is about 4 times more likely than in normal weight woman, and the risk of poor labour experiences including caesarean, forceps, infections, is greatly increased.
Professor Greer having set the scene and focused minds, the conference proceeded to reflect on the circumstances why in particular the guidelines have been developed and the challenges faced by the experts. Click here to download Management of Women with Obesity in Pregnancy Guidelines.
The next article covers the message delivered by Drs Caroline Overton and Kate Fitzsimons.
Obesity in Pregnancy – Management Guidelines to be published, London, 19th March 2010.
Centre for Maternal and Child Enquiries (CMACE) & the Royal College of Obstetricians & Gynaecologists (RCOG) will publish professional guidance on the management of women who are obese in pregnancy.
This is very good news for women and professionals alike, when it comes to managing obesity and overweight in pregnancy. After a lot of effort by many individuals and professionals bodies, guidelines for the care of women at high risk of complications during pregnancy and labour will now be available.
Until it is now, there has been little co-ordinated management advice to professionals that considered the obese woman holistically.
The guidelines are a result of recommendations made after the last Confidential Enquiry into Maternal and Child Health: Saving Mothers’ Lives – Lewis, G. (ed) 2007 that found that more than 50% of women who died from Direct or Indirect causes were either obese or overweight.
This guidelines will be a start, and complement other initiatives that seek to address the problem of obesity in society.
Care of the pregnant obese or overweight woman in the hospital will be streamlined and co-ordinated between different professionals.
Must our hope that the high morbidity and mortality associated with obesity will start to fall as a result of the guidelines. Confidential Enquiries are credited for creating an audit process that has led to falling maternal death rates in the UK. The enquiry process and resulting practice recommendations have been replicated across the world.
Although these guidelines will provide a template for the care of the pregnant woman, it is not certain there will be much in there for the woman after pregnancy. This would make the service we have set up for the weight loss after pregnancy timely indeed.
I will be reporting back from the launch of the CMACE/RCOG joint guideline: Management of women with obesity in pregnancy soon after the conference.