February 2011


The institute of medicine is widely recognized as setting guidelines for pregnancy.  The last time they revised their estimates was in 1990.  Since then the obesity epidemic has boomed.  Kathleen Rasmussen, ScD, PhD, and IOM committee chairwoman expressed “during pregnancy many women gain substantially more than we would like.”  The new guidelines are similar to the past, but now the obese women have an upper limit.  No one should lose weight while pregnant.

So what is the magic answer?

First, figure out your BMI.  Body mass index.   weight (pounds) / [height (ininches)]2 x 703.  For those who don’t want to do the math, go to the calculator here: http://www.cdc.gov/healthyweight/assessing/bmi/adult_bmi/english_bmi_calculator/bmi_calculator.html  This is a fairly reliable way of figuring out body “fatness” in most people. It doesn’t directly measure your fat, but research has shown BMI correlates with accurate measurements of body fat.

What are the categories?

  • If your BMI is less than 18.5= underweight
  • BMI is 18.5 to 24.9= normal or healthy
  • BMI is 25.0 to 29.9= overweight
  • BMI is 30.0 or higher= obese

 

SO. the IOM guidelines?

 

If you are pregnant with ONE child:

  • Underweight: Gain 28-40 pounds
  • Normal weight: Gain 25-35 pounds
  • Overweight: Gain 15-25 pounds
  • Obese: Gain 11-20 pounds

If you are pregnant with TWINS :

  • Underweight: no guidelines due to insufficient data
  • Normal weight: Gain 37-54 pounds
  • Overweight: Gain 31-50 pounds
  • Obese: Gain 25-42 pounds

So most likely,  to do this, you need to eat basically what is your normal.  Exercise.  Don’t think of this time as “eating for two.”  If you do, in addition to gaining more weight than you should (which leads to a host of other issues), you will be hurting your body’s ability to bounce back after pregnancy.  Trust me- as a plastic surgeon, I see it all the time.

Yes, yes.  We have all heard it.  “Have another piece of cake.  You are eating for TWO.” 

Egads.  Back in my mom’s day, women didn’t gain much weight with pregnancy.  15 pounds was likely normal.  I know a woman who was told by her doctor (remember this is a long time ago…) to start smoking (!!) as she was gaining too much weight with one of her pregnancies.

You don’t need many extra calories for your little bun in the oven.  According to a nutritionist, you need more nutrients during pregnancy, but not more calories. In the first trimester you need no extra calories.  In the second trimester you should have an extra 350 cals/day,  and in the third 450 cals/day. 

Which nutrients? Protein (recommendation is an extra 20g/day), folate (extra 50% of normal rec), iron (50% more than normal, so about 27mg/day total), and zinc. Don’t take any supplements though without checking with a doctor or registered dietitian because too much of certain vitamins is bad.

As far as weight gain, according to guidelines, you should gain 25-35 pounds if you are a normal “healthy” weight when  you begin your pregnancy.  If you are 5’6″, to be at a healthy weight when you start means you should weigh 118-148 pounds.  If you weigh over 150 pounds you are “overweight.”  If you weigh 186 pounds you are obese.

See my blog on BMI and weight gain recommendations by the IOM.

This is the beginning of a series of blogs about pregnancy and weight gain.  Pregnancy is not a time to go hog wild eating whatever you want.  There are guidelines to how much weight you should gain, and they vary with what your pre pregnancy weight is.

For those with no attention span (and can’t read past a twitter title), the findings were 

  • the higher your BMI, (underweight–>normal–>overweight–>obese), and
  • the more your weight gain past recommendations during pregnancy,

the higher your chance of high blood pressure during pregnancy. (High blood pressure during pregnancy is bad.)

Terms:

BMI= Body mass index. To calculate yours, here is a link from the US department of health  :http://www.nhlbisupport.com/bmi/bminojs.htm

PPBMI= Your prepregnancy BMI

IOM= Institute of Medicine.  It has guidelines recommending how much you should gain.  Those will be posted in another blog, but if you are normal weight, you average weight gain during pregnancy should be around 30 pounds, if obese around 15 pounds.

Study: American Journal of Perinatology Jan 2011

  • Evaluated new Institute of Medicine weight gain guidelines within each PPBMI category
  • Patients with singleton term deliveries
  • Women without history of  heart disease, diabetes, or pregnancy high blood pressure
  • Pregnancy high blood pressure rates were compared overall and within each PPBMI group
  • Looked at women gaining less than recommendations, within recommendations, and above recommendations

 

FINDINGS:

  • High blood pressure during pregnancy was higher when your prepregancy BMI was higher (5.0%, 5.4%, and 10.8% for less than, within, and above recommendation groups, respectively ( P < 0.001).
  • Above recommended weight gain resulted in higher high blood pressure incidence within each PPBMI category (underweight 7.6%, normal weight 6.2%, overweight 12.4%, and obese 17.0%), reaching statistical significance in all but the underweight PPBMI group.
  • Excessive weight gain above established guidelines was associated with increased rates of high blood pressure. 
  • Regardless of PPBMI, women should be counseled to avoid excessive weight gain during pregnancy.

So if you are considering getting pregnant, or you are pregnant, look at your BMI and weight gain.  It is important for your health and your pregnancy.  In general, as a plastic surgeon who specializes in the mommy makeover, I see women who don’t fare well with pregnancy.  Weight gain is part of that issue.

I am a plastic surgeon.  I perform a lot of breast augmentations.  I am lucky- most of my patients come to me after they have children and are done with breastfeeding. 

Any surgery to the breast will affect the breast.  This seems obvious, but it is something I always discuss with patients, particularly if they have not had children yet. 

If someone comes to me in their mid 30s and wants to have kids, I will counsel them to wait to have surgery until they are done having kids.  Your breasts get larger when you are pregnant and breastfeeding anyway.  Your breast changes with pregnancy and breastfeeding–after you are done with kids most women end up smaller in volume, so the size they would choose would change. (Some women do end up larger in breast size after kids, but don’t hold your breath for that one- it isn’t as common.)

So. Back to the title of this blog- if you have a breast augmentation, does it affect your future ability to lactate (ie breastfeed)?

Yes.

A study came out in Breast Journal, Jan-Feb 2007 out of the UK.  I have a few issues with the study, particularly one of their opening lines which I think is really untrue, “It does not occur to most women to consider the possible effects of breast augmentation surgery may have on their future ability to exclusively breastfeed their baby.”  Maybe it is because I live in the hypereducated Silicon Valley Palo Alto area, but I think all of my patients consider the effect of any breast surgery on their future ability to breastfeed, and it is part of my usual discussion, particularly with regards to incision site. 

But back to the study, which I am citing because it did bring out some interesting facts. 

  • Women who have breast augmentation surgery have a greater   lactation insufficiency.  NOTE: This does not mean they do not produce milk, but they may not be able to exclusively feed their child by breast milk alone to meet their parameters of weight gain.
  • Factors related to surgery include impairment/loss of nerves to the nipple areola complex, which lead to reduced sensation and loss of the suckling reflex resulting in decreased milk production.
  • complications in surgery (hematoma, need for additional surgery, capsular contracture, etc) can lead to impairment.

Their conclusion? “With good surgical technique and proper postoperative management, most of the complications associated with surgery that may result in insufficient milk production can be minimized but not always avoided.”

So what does this mean? This study would not change my general advice to women, which is:

  • If you are in your early 20s and have a good decade before having kids, in the pros/cons of deciding to do breast surgery, you need to factor in potential decrease in your ability to breastfeed.
  • I have had many patients who have successfully breastfed after breast augmentation.  This study shows a decreased amount of milk production, and it varied due to multiple factors.  Their final statement was that good technique and proper postop management you can minimize the impairment.
  • IF YOU ARE WITHIN A YEAR OR TWO OF HAVING A BABY, WAIT.  I counsel women to do this all the time. I get that having larger breasts will make your wedding dress fit better, but if your plan is to get married and then start a family right after, wait to do the surgery.
  • IF BREASTFEEDING IS OF PARAMOUNT IMPORTANCE and you would be upset to supplement with formula if needed, WAIT.  I know this is controversial in my plastic surgery world where many doctors have become salesmen for procedures, but you have to look at your life big picture when looking at these things.

Remember also, some women can’t breastfeed for whatever reason who have never had breast surgery.  There are no guarantees.