A midwife I was talking to asked me the other day:
'How can I give diet advice to obese pregnant women, when I'm overweight myself?'
I've thought and read about midwives and obesity for a few days, and I've got an answer. But first I want to talk about what I found when reading: we overlook the intense psychological anxiety obese people feel. Surely this is significant?In background to this topic, 25% of women in the UK were obese in 2012. You probably know already that obese women are more at risk of miscarriage, stillbirth, abnormalities in their babies, gestational diabetes, pre-eclampsia, thromboembolism, and caesarean birth (according to RCOG).
There's intense stigma towards obese people, and it definitely stretches to healthcare. I'm not even going to quote studies, just think about the last time you cared for someone who was morbidly obese. Can you remember anything unpleasant that was said about them? I certainly can, and my last work place was staffed by compassionate and empathetic midwives.
Assumptions include: obese women are lazy, stupid, and have got themselves into this mess by being weak willed. But there's every reason to suspect losing weight isn't the simple 'eat less move more' idea we're pushing, and we're making it worse by pushing shame.
For a start, advice is confusing:
- The NHS say base your diet around starch, fruits and veg, reduce saturated fat, and perhaps try orlistat, which blocks 1/3 fat absorption
- WHO recommend reducing fat intake as well, but say you can eat <10% 'free sugars' (don't really know what that means?!)
On the other hand...
- Many obesity researchers recommend animal protein and especially saturated fat, arguing you can't possibly lose weight if you base your diet around carbs...
- ...but, a very large cohort study among other sources suggested eating red meat is associated with increased risks of cancer, cardiovascular disease, and faster mortality.
- There's growing evidence suggesting fasting is good for weight loss (how surprising!), and can also slow aging, reduce cancer, heart disease and cognitive decline....but the NHS say fasting isn't the best idea.
How are obese women supposed to commit to a life changing, usually if we're honest, quite painful regime without knowing if it's safe, healthy, or even if it'll work?
One study from the University of Florida found patients who'd got to a more normal weight through gastric band surgery said they'd rather be blind, deaf, or an amputee than be obese again.
And there's this heartbreaking quote from an obese woman:
I don’t like looking at my body. Not at all. When I look at it I feel sick. My legs rub together, my belly hangs and every minute I’m trying to pull my trousers down and put my top down when I'm walking.
That's how much people want to avoid being obese. So this being the case, can we really just assume it's a matter of willpower?
I know there are some people out there who'd argue shame can be a powerful motivator. And to be fair, I can relate to this, there have been times during my life when I've been 'shamed' into working hard because I've failed a test or done something silly. But I can tell you if I had absolutely no-one who thought I was worthy of respect, I'd have found it really hard to put that work in.
And also, should we as healthcare professionals push shame on clients in our care? Should we use shock tactics? Last time I checked with the NMC code our role was about supportive and respectful care.
Back to the original question which was asked me by a gorgeous midwife who's desperate to do right by her client. How can you advise on weight loss when clearly you're struggling with this issue yourself?
My answer is, I believe obese mothers are even more in need of a 'with woman' midwife. And overweight midwives can be in a really good place to provide this care.
How are obese women supposed to have the energy make complex changes if they have no confidence? This is one of the areas where midwives can make most impact. I think we need to get women talking about how they feel, what the options are and try and get them support.
For instance, intuitive eating is one area of research that looks promising (the scope of the topic is outside this post, but the link is to a study showing that diets can actually cause long term weight gain - so learning to eat in a psychologically healthy way might be a good way forward).
If you're overweight, I believe you're in an excellent position to support these women with empathy. Obviously, the risks of gaining weight in pregnancy and not losing weight when postnatal are too big to be ignored. We have to give accurate information. But I'd be ashamed if I didn't listen, respect and empathise with women experiencing such sensitive pain.
I'm not perfect and to my embarrassment I have had those judgemental times - but I recognise this is me at my worst as a midwife.
I've scoured the official guidelines of RCOG, and WHO, and I can't find any info on how we're supposed to address the stigma. Or how to care for obese or overweight women psychologically, which seems a bit of an oversight.
More focus is needed on the psychological and emotional issues linked to weight management.
As midwives, can we start this now?
I'd love to hear from you. Do you have experience as an overweight mum or midwife? Do you think it's safe for midwives to show respect for obese women? Or should we be using shock tactics?