New Mothers 15/5/03 11:24 AM Page i
PROFESSOR TRIM’S QUICK START
New Mothers 15/5/03 11:24 AM Page ii
PROFESSOR TRIM’S PROFESSORS Professor John Blundell PhD, C Psychol, MBPS Professor of Bio-Psychology, Leeds University, UK and Board Member of the International Association for the Study of Obesity (IASSO) Professor Wendy Brown BSc (Hons), MSc, Dip Phys Ed, PhD Professor of Physical Activity and Health, University of Queensland Professor Ian Caterson MBBS, BSc (Med), PhD, FRACP Boden Professor of Human Nutrition, Sydney University and Vice President, IASSO Professor Terry Dwyer MBBS, MPH, MD, FAFPHM Director Menzies School of Health Sciences Hobart, and University of Tasmania Professor Garry Egger MPH, PhD, MAPS Director, Centre for Health Promotion and Research Sydney Adjunct Professor of Health Sciences, Deakin University Professor James Hill PhD Director, Center for Human Nutrition, University of Colorado Health Sciences Center and Co-Founder, National Weight Control Registry Professor Kerin O’Dea BSc, PhD Director of Menzies School of Health Research, Darwin Professor Stephan Rossner MD, PhD Director, Obesity Research Program, Luddinge Hospital, Stockholm, Sweden and Past President of IASSO Professor Boyd Swinburn MD, MBChB, FRACP Professor of Population Health and Nutrition, Deakin University Professor Klaas Westerterp PhD Professor of Human Energetics, Head of Department of Human Biology, Maastricht University, The Netherlands
New Mothers 15/5/03 11:24 AM Page iii
PROFESSOR TRIM’S THE
QUICK START WEIGHT-LOSS PROGRAM
for new mothers and mothers-to-be Dr Katherine Samaris MB, BS, PhD, FRACP
Dr Garry Egger MPH, PhD, MAPS
New Mothers 15/5/03 11:24 AM Page iv
First published in 2003 Copyright © Katherine Samaris 2003 Copyright © Garry Egger 2003 All rights reserved. No part of this book may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopying, recording or by any information storage and retrieval system, without prior permission in writing from the publisher. The Australian Copyright Act 1968 (the Act) allows a maximum of one chapter or 10% of this book, whichever is the greater, to be photocopied by any educational institution for its educational purposes provided that the educational institution (or body that administers it) has given a remuneration notice to Copyright Agency Limited (CAL) under the Act. Allen & Unwin 83 Alexander Street Crows Nest NSW 2065 Australia Phone: (61 2) 8425 0100 Fax: (61 2) 9906 2218 Email:
[email protected] Web: www.allenandunwin.com National Library of Australia Cataloguing-in-Publication entry: Samaris, Katherine. Egger, Garry. Quick start weight-loss program for new mothers and mothers-to-be. ISBN 1 74114 117 6. 1. Weight-loss. 2. Women–Nutrition. 3. Physical fitness for women. I. Title. (Series: Professor Trim’s medically supervised weight-loss programs). 613.7045 Set in 11/12.5 pt Adobe Garamond by Midland Typesetters, Maryborough, Victoria Printed by Griffin Press, South Australia 10 9 8 7 6 5 4 3 2 1
New Mothers 15/5/03 11:24 AM Page v
CONTENTS Introduction How to use Professor Trim’s Quick Start Weight-Loss Program for New Mothers and Mothers-to-be
vii
Part 1 2 3 4
3 9 20 27
1 Background Obesity and the modern environment General nutrition for weight management More movement makes mightier mums Stressing up for (more) dinner
Part 2 Motherhood Pre-pregnancy 5 When weight gets in the way
35
Pregnancy 6 A natural process 7 Special nutritional requirements in pregnancy 8 Special considerations in pregnancy
45 54 60
Post-partum 9 Weight management after childbirth 10 Myths associated with pregnancy and body weight
65 71
Appendix Purchasing Professor Trim’s Medically Supervised Weight-Loss Programs
77
New Mothers 15/5/03 11:24 AM Page vi
ABOUT THE AUTHORS Garry Egger is Director of the Centre for Health Promotion and Research in Sydney and Adjunct Professor of Health Sciences at Deakin University. He has been involved in health promotion for almost 30 years and is the author of more than 25 books. Katherine Samaris is a Consultant Endocrinologist at St Vincent’s Clinic and St Vincent’s General Hospital, Sydney. She is actively involved in diabetes and obesity research at the Gavin Institute of Medical Research.
New Mothers 15/5/03 11:24 AM Page vii
INTRODUCTION: How to use Professor Trim’s Quick Start Weight-loss Program for New Mothers and Mothers-to-be The Professor Trim’s (PT) Quick Start program in this book is an introduction to effective weight loss, and a lifetime of weight management, for new mothers and mothersto-be. It differs from other pregnancy advice in that it’s aimed mainly at mothers—although never neglecting the health of the baby. Most information for new mums, you’ll find, is focused on the health of the child. And while no one would deny the importance of this, the ongoing health of the mother often seems to be forgotten. Pregnancy and childbirth are critical periods for weight gain in women and the weight that’s gained at these times is often difficult to lose over the long term. Since excess body weight can be a health risk, it’s crucial that all the best available scientific information be put into helping women at these stages in their life. This doesn’t mean ignoring the needs of the baby. Indeed, as we will see, maintaining ideal weight and good health in the mother is likely to improve childbirth outcomes. The Professor Trim program is designed to do just that. vii
New Mothers 15/5/03 11:24 AM Page viii
NEW MOTHERS AND MOTHERS-TO-BE
PROFESSOR TRIM’S—THE HISTORY Professor Trim’s evolved from the ‘GutBuster’ program, which started as a men’s ‘waist-loss’ program in 1991. GutBusters became the biggest, and most successful, men’s weight-loss program in the world. It had an internationally acclaimed scientific advisory board and was consistently rated by consumer groups as among the best weight-loss programs available. Initially designed for men, GutBusters soon developed a program for women. Hence the Professor Trim’s range of programs—for men and women, and these Quick Start versions. Several thousand Australian doctors (see www. professortrim.com) have had special training in weight control as part of a Postgraduate Medical Certificate in Weight Control and Obesity Management from Sydney University. These doctors, and the Professor Trim’s Medically Supervised Weight-Loss Program, can help new mums through a shared-care system that provides the best information available on weight loss and weight management.
MORE PROFESSOR TRIM’S ADVICE More intensive individual programs will continue the quick start to weight loss you’ll get from this program. Information about the full Professor Trim’s programs are contained in the back of this bookset. You can also purchase these directly from your PT doctor and work with him or her through the full twelve months of the program, or longer. The way to get the greatest benefit from this Quick Start new mum’s program is first to read the book. You can then access regular updates on current research and viii
New Mothers 15/5/03 11:24 AM Page ix
INTRODUCTION
information from the Professor Trim Internet site at www.professortrim.com. At the end of each chapter in this booklet you will find an easy-to-follow summary of its contents, contained in a Professor Trim’s Prescription Pad. Use these summaries as your checklist for putting the program into action.
STRUCTURE OF THE PROGRAM The information contained in this book is divided into two parts. The first part, ‘Background’, provides a summary of general weight loss information—nutrition, physical activity and stress management in particular— to set the stage for modifications to this with motherhood. The second part, ‘Motherhood’, discusses the specific requirements for weight management before, during and after pregnancy. The reason that both the ‘before’ and ‘during’ pregnancy periods are considered so important here is that taking preventable action in these stages can make long-term weight control after childbirth much more manageable. Best results are likely to be achieved by fully preparing for weight management in the pre-pregnancy, ‘before’ phase. Since about half of all pregnancies are unplanned, however, we appreciate this is not always possible. Hence actions taken during pregnancy might represent the first attempt to deal with a weight problem. Where action is left until after delivery, the problem becomes more difficult, but not impossible to solve. Women reading this who have already put on weight after giving birth should consider all of the advice as part of their preparation for any future pregnancies. For those who have finished their family, the complete Professor Trim’s ‘Becoming Slimmer’ program for women is another alternative. ix
New Mothers 15/5/03 11:24 AM Page x
NEW MOTHERS AND MOTHERS-TO-BE
Professor Trim’s Prescription Pad • •
Read this booklet first. Try to put the recommendations at the end of each chapter into action. • Check in at the Professor Trim Website (www.professortrim.com). • Check in with your Professor Trim doctor for ongoing help. • For more specific programs, and a ‘personal weight coach’, see the Appendix on page 77.
x
New Mothers 15/5/03 11:24 AM Page 1
Part 1 Background
New Mothers 15/5/03 11:24 AM Page 2
New Mothers 15/5/03 11:24 AM Page 3
Chapter 1 OBESITY AND THE MODERN ENVIRONMENT OBESITY—THE MODERN EPIDEMIC Through thousands of years of evolution, humans were kept lean by the effort required either to eat or avoid being eaten. The ultimate goal was comfort—food on the table at the end of the day, without having to toil too hard to get it. By the twenty-first century this goal has been largely achieved. But what nature gives on the roundabouts, it takes on the swings. Obesity and overweight are the price we pay for technological advancement and modernisation. At the turn of the millennium, more than two in every three Australian men and one in every two women were classified as overweight. And although we don’t have comparative figures for historically earlier times, it’s certain that the numbers of overweight would have been minute, compared with today. Women fare particularly badly in this new world because, biologically, they have been designed to get fat more easily, and to store fat more efficiently, than men. This is because the survival of the evolving human race meant it was necessary for a woman to both survive the nine months of pregnancy and to nourish the baby afterwards. To do this their bodies had to lay down extra energy reserves (i.e., fat) as a form of insurance against famine, a process which became very effective. And while the trials of day-to-day life in past ages ensured that the 3
New Mothers 15/5/03 11:24 AM Page 4
NEW MOTHERS AND MOTHERS-TO-BE
effects of weight gain were readily counteracted after childbirth, the easier way of life in our modern environment makes this weight loss no longer automatic.
PREGNANCY AND BODY WEIGHT Pregnancy is a period of necessary weight gain in a woman, resulting not only from the weight of the growing foetus, but also from the extra reserves required to feed that foetus. Natural increases in hunger will normally drive the increase in body weight required for an ideal pregnancy. However, in the modern environment this ‘biological hunger’ is often confused with ‘learned appetite’ and hence the desire to eat may not necessarily be biologically driven. On top of this, there are tendencies in modern societies to condone ‘eating for two’ by a pregnant woman, even if this amounts to over-eating, and to be over-protective of a woman being too active during her pregnancy. As a result, pregnancy and motherhood have become almost synonymous with permanent weight gain. Yet a glance back through history tells us that this need not be inevitable. Women in hunter-gatherer and other subsistence existences rarely, if ever, gained permanent weight as a result of childbirth. Hence the problem can be seen to be associated with lifestyle, in particular, the nature of modern technological societies.
PREGNANCY AND THE HEALTH OF THE MOTHER Traditionally, recommendations for weight gain during pregnancy have been based on the health of the child. In the modern environment, inadequate weight gain to ensure a healthy baby is rarely the problem (except, of 4
New Mothers 15/5/03 11:24 AM Page 5
OBESITY AND THE MODERN ENVIRONMENT
course, in the case of special circumstances or pre-term delivery). The mother’s health, and the difficulty of regaining a healthy body weight after childbirth, now need to be taken into consideration in making recommendations for pregnancy weight gain. As post-partum weight retention is partly dependent on the amount of weight gained in pregnancy, it would seem illogical to suggest a greater gain in pregnancy than is necessary. The good news is that this means permanent weight gain doesn’t have to occur after childbirth. If lifestyle changes are the key to weight gain in women in modern technological societies after they give birth, the answer to preventing the problem lies in becoming aware of these changes and making the necessary adjustments to reduce their impact. This doesn’t mean going back to hauling water from the nearest freshwater spring or washing clothes by hand. But it does mean considering a longterm plan for weight management. The table below shows the factors that appear to be most associated with weight gain in new mothers and mothers-to-be. Factors identified as tending to increase weight gain in motherhood Pre-pregnancy weight Excess weight before pregnancy increases the risk of greater weight retention after giving birth. Gestational weight gain The bigger the gain during pregnancy, the greater the difficulty of shedding the excess weight. Number of pregnancies The difficulty in returning to ‘normal’ weight appears to increase with more births. Lower educational level Less educated women have more trouble losing post-pregnancy weight (suggesting that weight maintenance can be learned). 5
New Mothers 15/5/03 11:24 AM Page 6
NEW MOTHERS AND MOTHERS-TO-BE Later return to work or activity An earlier return to work or high activity levels can decrease the risk of weight retention. Not breastfeeding Although not always a factor, breastfeeding offers a ‘window of opportunity’ for long-term weight maintenance in the mother, as well as a reduced risk of later excess weight gain in the child. Extreme dieting Trying to diet excessively can lead to ‘breakouts’, or bingeing, when things go wrong, which result in even greater weight gain. Overeating, or ‘eating for two’ For many women, pregnancy is an excuse to eat whatever they like to satisfy their cravings. And while genuine cravings are an indication of need, these are often confused in an environment of unlimited foods. Post-partum depression This can lead to ‘comfort eating’ and reduced activity, both of which increase the prospects of weight gain
BEHAVIOUR CHANGE FOR WEIGHT LOSS Because weight control programs are a dime a dozen, it should be apparent that most don’t work. If they did, why would there be so many? It would also seem logical that one of the best ways to find out what does work is to ask those who have successfully lost a lot of weight and managed to keep it off for a long period. Researchers in the United States have done this. Dr James Hill from Colorado State University and his colleagues have established a National Weight Control Registry (NWCR) of a large number of people who have lost a minimum of 14 kilograms and kept this off for at least five years. These people have been subjected to a range of different forms of research, which has shown consistently similar conclusions about the best techniques for long-term loss. Five main factors stand out: 6
New Mothers 15/5/03 11:24 AM Page 7
OBESITY AND THE MODERN ENVIRONMENT
1. A lifestyle built around a high level of physical activity This doesn’t mean a regular commitment to an exercise regime (although this can help). Accumulated movement, or physical activity built into the lifestyle (adding up to at least 60–80 minutes a day for women), has the best effect. 2. A lifetime pattern of low-fat eating This doesn’t imply a ‘diet’ as such, but an ongoing reduction of foods that are high in fat and energy (calories). 3. Established techniques for managing stress Stress can be an issue in causing compensatory ‘comfort eating’. Ability to deal with day-to-day stresses is associated with better long-term weight management. 4. Self-monitoring This includes measuring such things as the number of steps taken daily (using a pedometer), the amount of fat in the daily food intake, the number of servings of fruits and vegetables eaten each day, etc. Self-monitoring is known to be one of the most effective methods available for making a range of behaviour changes. 5. Eating breakfast This is the most important meal of the day. Eating breakfast helps reduce food intake, and hence total energy, over the rest of the day. Other factors that seem to be important, particularly for women either contemplating pregnancy or about to become mothers, are: • Unlearning old habits These often die hard, but habits such as eating for comfort, or being passive instead of active, are often the cause of significant weight problems. The good news is that if they can be learned in the first place, they can also be unlearned. 7
New Mothers 15/5/03 11:24 AM Page 8
NEW MOTHERS AND MOTHERS-TO-BE
• Learning new habits Replacing negative ways of thinking with more rational, positive ways of thinking, is often as good as, or better than, any diet program for weight loss.
Professor Trim’s Prescription Pad • • • •
8
Weight gain is normal and healthy in pregnancy—but it can be too much in the modern environment, as well as too little. A number of factors are predictive of postpartum weight retention. Behaviour change—mostly reduced physical activity—is the main cause of weight gain after childbirth. Long-term weight loss maintenance is best achieved through a low-fat, reduced-energy eating plan, regular exercise, self-monitoring and establishing ways of dealing with stress.
New Mothers 15/5/03 11:24 AM Page 9
Chapter 2 GENERAL NUTRITION FOR WEIGHT MANAGEMENT In this chapter we’ll look at nutrition in general for weight loss and weight management. Some aspects may need to be modified when we consider individual phases of motherhood in later chapters, but the main principles as discussed here will still be appropriate.
NUTRITION FOR WEIGHT LOSS In general, nutrition for weight loss or weight management is the same as nutrition for good health. In essence this means: • Not eating too much; • Eating regularly; • Eating a wide variety of foods to get balanced nutrient intake; • Not skipping meals, or attempting overly restrictive dieting; and • Limiting rich, high energy dense foods. These principles apply generally throughout the stages of motherhood, from planning a pregnancy to after delivery.
FOOD VOLUME AND WEIGHT LOSS Despite the hype about different types of diets for weight loss, the issue basically boils down to the volume of food 9
New Mothers 15/5/03 11:24 AM Page 10
NEW MOTHERS AND MOTHERS-TO-BE
consumed in terms of total energy (calories or kilojoules), which can be expressed as: Volume = Energy density (kcals/g) × Portion size (g) There are many different ways in which volume can be decreased, some of which are associated with the type or amount of foods eaten, and others with the management of hunger. New mothers and mothers-to-be do need to eat more than most other women. But for many women in modern Australia, the problem comes with eating not just enough more, but eating too much more. It may be quite unnecessary to drastically increase food intake during pregnancy—particularly for those who are already overweight. More important is a varied diet and an adequate volume of food for the long-term benefits of both mother and child. Here we consider the main factors accepted scientifically as influencing food volume and quality.
REDUCING DIETARY FAT There’s been a lot of controversy recently about whether fat or carbohydrate is the most important nutrient in weight control. The answer should be clear; it’s total energy (calories or kilojoules) that is important, irrespective of where these come from. However . . . because there are 38 kJ per gram in fats and oils (remember oil is just a liquid form of fat) and only 17 kJ per gram in carbohydrate and protein, it’s much easier to take in more calories through fat. The long and the short of it is, if you can reduce fats in your diet (including those commonly regarded as good fats, such as olive oil), even throughout pregnancy, 10
New Mothers 15/5/03 11:24 AM Page 11
GENERAL NUTRITION FOR WEIGHT MANAGEMENT
you’ll go a long way to preventing a long-term weight problem. Here are some simple ways to do this: • Don’t use spreads like butter and margarine (or at least spread them thinly) While some of the new designer margarines may help your cholesterol, they’re still up to 80 per cent fat (at 38 kJ) and just add to your weight woes. • Take the skin off chicken Birds store fat under the skin. Animals store it more throughout the muscles. Take the skin off before cooking, so you’re not tempted to eat it afterwards. • Don’t fry food in oils or butter Grill, bake, boil, steam . . . whatever you like. Frying in oil results in the 38 kJ being soaked up by the food and, ultimately, stored on the body. • Cut all visible fat off meat Fat on meat is easy to see. It’s the white bits around the outside of the T-bone or the grainy white bits throughout other forms of red meat. Go for the low-fat meats, which are generally whiter meats like veal, pork and spring lamb. Otherwise trim all the fat off before cooking—it’s too tempting after it’s been cooked. In case you’re wondering, it’s not necessary to eat meat for a healthy pregnancy—unless you want to. If you don’t like meat there’s no need to force it down, as long as you are eating a wide variety of foods, including some rich sources of protein (like beans and lentils). The addition of a multi-B vitamin and a folate supplement (from a reputable supplier) is advisable. • Avoid full-cream dairy products Cheese and fullcream dairy products are large sources of fat. Milk 11
New Mothers 15/5/03 11:24 AM Page 12
NEW MOTHERS AND MOTHERS-TO-BE
can be modified by going for the low-fat versions (preferably one containing added calcium), but it’s hard to get a true low-fat cheese. For this reason cheese should be eaten in moderation.
WHAT IS LOW FAT? To take the low-fat issue further than just the five tips above, you’ll need to understand a bit about fat. There are a couple of simple rules to work by. The Professor Trim program stipulates that you should: • Avoid foods with more than 10 per cent fat How do you know if a food is more than 10 per cent fat? Look for Professor Trim’s Ultimate Food Energy Guide at any bookstore (a copy is supplied with each full Professor Trim program). This will tell you the number of grams of fat per 100 grams in a stack of different foods. If a food has more than 10g/100g (i.e., 10 per cent) fat, avoid it. In fact, ban it from the house. • Reduce your daily fat intake Again, from your Ultimate Food Energy Guide you can check on just how much fat you are eating in your diet. Check the quantity of each food eaten and the number of grams of fat it contains. Then try to reduce your daily fat intake to around 30g a day or less.
INCREASING DIETARY FIBRE Fibre is mostly the ‘stringy’ part of foods, like the bits of an orange that hold it together, or the bran on the outside of a grain. There are different types of fibre, but for our purpose here we’ll consider them all together and make 12
New Mothers 15/5/03 11:24 AM Page 13
GENERAL NUTRITION FOR WEIGHT MANAGEMENT
the assumption that most high fibre, low energy dense foods, such as fruits and vegetables, come from plants. However fibre also exists in some manufactured foods, such as bread, pasta and cereals. Through increasing your fibre intake you’ll decrease your fat intake, and thus have a double effect on your excess body weight. A simple formula is to eat at least three different fruits and four different vegetables a day, and to increase your intake of pasta, breads (without spreads) and cereals.
INCREASING THE PROPORTION OF PROTEIN Protein is muscle food. It comes mainly from the muscles of the animals we eat, but other good low-fat sources are beans, legumes and some other vegetables. Protein is of particular importance during pregnancy because of the need to create new body tissue. Because protein goes into muscle in our bodies, and muscle is active, it helps to increase metabolic rate— provided this is combined with exercise (see Chapter 3). Protein is also generally not turned to fat, because any excess is lost as heat or passed out through the urine. It’s important that the proportion of protein in your diet is increased, not necessarily the total amount. This doesn’t mean eating more food, as protein is a significant source of food energy. It’s also important to make sure an increase in protein comes from low-fat sources. The table on the next page lists some good sources of such protein. Seafood is a good source of protein and also has benefits for blood fats like cholesterol. Recent research has shown that eating more fish can improve birth outcomes 13
New Mothers 15/5/03 11:24 AM Page 14
NEW MOTHERS AND MOTHERS-TO-BE
Some low-fat sources of protein Seafood
Vegetables
Meat
Fish (most kinds) Prawns Lobster Crab Squid/octopus Oysters (cooked, not raw)
Legumes Lentils
Kangaroo Crocodile Lean beef Lean pork Lamb Chicken breast Lean beef
in pregnant women and hence eating two or three seafood meals (not fried or raw) per week should be a standard recommendation for good health and weight management.
DECREASING ENERGY DENSITY ‘Energy density’ is a relatively new term that refers to the number of calories (kilojoules) per gram of food. The reason it’s now used is that sometimes it’s not just fat which adds to total calories, but high quantities of sugar and/or fat. Energy density is calculated by dividing the number of kilojoules in a food by the number of grams of that food. Where this turns out to be less than 12.5kJ per gram of food (3cals/g), it implies a high energy dense food that should be avoided. Between 7.5 and 12.5kJ/g is medium and below 7.5kJ/g is low energy density and can be eaten in (almost) unlimited quantities (For a summary of foods and their energy density see Professor Trim’s Ultimate Food Energy Guide). The energy densities of some well-known foods are given in this table. 14
New Mothers 15/5/03 11:24 AM Page 15
GENERAL NUTRITION FOR WEIGHT MANAGEMENT
Some low-fat but high energy dense foods Food Biscuit: savoury crispbread, puffed and toasted Biscuit: fruit, polyunsaturated, wholemeal Bread: melba toast Breadstick: hard Breakfast biscuit, wholewheat, bran Cereal (mixed grain, sugar more than 35%, fortified) Confectionery, carob coated, sugar Cornflakes Fudge, not chocolate, plain Muesli, toasted Mousse, low-fat, chocolate, artificially sweetened Popcorn, air-popped, no added fat Pretzel, regular Rice cake, natural, brown Rice cake with corn and sesame Turkish delight, chocolate-coated
Fat ED kcals/g (g/100) (kJ/g) 3.8 9.9 4.9 3.8 7.6
3.8 3.9 3.8 3.9 3.5
(16.1) (15.9) (16.0) (16.3) (14.9)
4.2 9.9 0.5 4.2 9.8
3.8 4.2 3.7 3.8 3.9
(16.1) (17.5) (15.6) (16.1) (16.2)
5.0 4.2 7.2 3.4 2.5 9.8
3.9 3.5 3.8 3.7 3.9 4.0
(16.3) (14.8) (15.8) (15.6) (15.0) (16.6)
REDUCING TOTAL ENERGY (CALS)/kJs Whether we’re looking at fat, carbohydrate or protein, at the end of the day it’s still the total amount of energy (calories or kilojoules) that causes a weight problem. If you’ve cut back on fatty foods and high energy dense foods it’s almost impossible to eat too much food— almost! But eating the right sorts of food for some people can still be a problem, for while food quantity may need to be increased during pregnancy, it does not need to be 15
New Mothers 15/5/03 11:24 AM Page 16
NEW MOTHERS AND MOTHERS-TO-BE
increased greatly. In women who are already overweight, the actual quantity of food eaten may not need to be increased at all. On the other hand, it is vital that a pregnant woman does not diet, or excessively restrict her food intake. Moderation is the key to a healthy pregnancy and pregnancy outcome.
INCREASING VARIETY This may not sound right, given the above and that it implies eating more food. But that’s not necessarily the case. By eating a wide variety of even small amounts of foods, you are guaranteed to get all the vitamins, minerals and nutrients you need for having a healthy baby—even if this food is low in energy. Try to eat at least 40 different types of (good) food a week. Remember though, this has to tie in with the rules outlined above, which means foods which are low-fat, low energy dense and low in total energy. So you’ll be looking for variety in fruits, vegetables and other unprocessed foods—even spices.
EATING REGULARLY Eating regularly doesn’t mean eating more. It can mean eating less, because it helps to satisfy hunger better. Research suggests that eating several small meals, instead of one or two large meals a day, will decrease cholesterol in the blood; it will also lead to less reduction in metabolic rate, which is what happens when people skip meals. In particular, don’t go without breakfast. If possible, try to eat at least every four hours—but make sure it’s something healthy, like fruit or a lowfat snack. 16
New Mothers 15/5/03 11:24 AM Page 17
GENERAL NUTRITION FOR WEIGHT MANAGEMENT
MANAGING HUNGER When we talk about managing hunger, we’re not concerned with genuine biological hunger. What we are interested in is managing learned appetite. Few of us these days eat when we are genuinely hungry. We eat when it’s time to eat, when we are with friends, when we have a cup of tea, when we feel sad or need to relax, or when some other learned stimulus tells us we should eat. Many mothers-to-be eat extra not because they are hungry, but because they feel they have to, or because they are pressured by those around them to eat ‘for the good of the baby’. We all need to recognise genuine hunger again. Many stimuli in the modern environment, such as fast food takeaways, food packaging, the layout of shopping centres, to mention but a few, are designed to make us eat at times of the day when we don’t really need to. Having eaten once in association with some other normal activity, the chances are that we will do it again the next time that situation occurs. For example, having a piece of cake with a cup of tea can end up always meaning ‘cup of tea = cake’. Stopping ourselves doing this means: (a) first of all recognising the link between behaviour and food, and (b) making changes to break this link. A lot of what we consider to be hunger could be called ‘pseudo-hunger’. Often what we consider as having a ‘big appetite’ is merely having learned to eat too much. It’s important to differentiate between the two, particularly during pregnancy when biology may be confused with psychology. So here are some tips to help you: 1. Deal with those situations where ‘pseudo-hunger’ is making you over-eat. 2. Recognise the difference between real hunger and learned appetite. 17
New Mothers 15/5/03 11:24 AM Page 18
NEW MOTHERS AND MOTHERS-TO-BE
3. Don’t eat treats (e.g., chocolate) when you are hungry—it makes you learn that only treats satisfy hunger. 4. Fill up with high fibre, low-fat foods. 5. Don’t get hungry—eat small, eat often. 6. Respond to your genuine food cravings during pregnancy, but make sure these are genuine. 7. Don’t be pressured to over-eat during pregnancy by well-meaning friends and relatives. 8. Don’t diet or overly restrict your food intake. 9. Be flexible, not rigid in your food habits. 10. Eat a wide variety of foods to guarantee a sufficient nutrient intake.
Professor Trim’s Prescription Pad • • • • • • • • •
18
Try to reduce the total volume of food energy in your diet. Do this firstly by reducing fats and sugars and increasing fibre. Increase the proportion of low-fat protein. Increase the variety of foods to more than 40 different foods a week. Eat small, eat regularly. Don’t miss breakfast; don’t go for longer than about four hours without something to eat. Don’t use butter and margarine (or spread them thinly). Take the skin off the chook or turkey—before you cook it. Don’t fry foods in oils.
New Mothers 15/5/03 11:24 AM Page 19
GENERAL NUTRITION FOR WEIGHT MANAGEMENT
• • • • • •
Cut the fat off meat. Avoid full-cream dairy products. Avoid foods with more than 10 per cent fat; check labels for fat content. Eat more low energy dense foods and less high energy dense foods. Eat less total food. Recognise genuine hunger and don’t respond to ‘learned appetite’.
19
New Mothers 15/5/03 11:24 AM Page 20
Chapter 3 MORE MOVEMENT MAKES MIGHTIER MUMS THE IMPORTANCE OF BEING ACTIVE Most weight control programs begin with a ‘diet’. Exercise, is then often added as an afterthought. But recent research has shown that this may be the wrong way round. A lifetime program of planned and ‘incidental’ movement, particularly in a technological environment where daily movement has been ‘engineered’ out of most lives, is likely to have the best long-term effect on weight loss. The type of activity required, however, may be quite different to that which is often considered. In pregnancy, the type and intensity of movement will also change as the pregnancy progresses; this aspect will be considered later. In this chapter we’ll look at the requirements for exercise in general for weight maintenance.
MOVEMENT TYPE AND INTENSITY New findings suggest it is not necessary to follow the old concept of vigorous exercise at high intensity for weight loss. Energy use is the main requirement, and this comes from all forms of accumulated movement (that is, movement not necessarily done all at the one time). In essence, as with food intake, the issue with physical activity is volume, which can be expressed as: Volume = Frequency × Intensity × Duration 20
New Mothers 15/5/03 11:24 AM Page 21
MORE MOVEMENT MAKES MIGHTIER MUMS
If intensity of activity is increased, frequency and duration can be decreased. But where it is potentially dangerous or disadvantageous to increase intensity, benefits can be gained from increasing frequency and duration. This is good news for new mothers, for whom intense activity is not only difficult but can also be dangerous. The more you move your body, however, irrespective of how this is done, the less chance it has of storing unused energy as fat. The main goal of a weight management program therefore should be to increase movement. This can be done in two ways: (1) by increasing the ‘incidental’ activity that would otherwise be done by machines in day-to-day living, and (2) by planning for extra (accumulated) activity throughout the day.
INCIDENTAL ACTIVITY Incidental activity includes: • walking instead of driving; • not using remote controls (e.g., for the TV); • reducing the use of effort-saving machinery (e.g., leaf-blowers) and doing things by hand; • standing instead of sitting; • not using emails where walking to give someone a message is easy (in an office); • doing things yourself instead of asking others; and • using the stairs instead of lifts or escalators. It helps to consider all the things you do each day and plan to make your day more physically active. It’s a bit of a mind shift: we have all been trained to be efficient with our use of time and effort for the past 50 years. You’ll need to turn this around and think of how you can ‘waste’ physical effort in performing your daily tasks. 21
New Mothers 15/5/03 11:24 AM Page 22
NEW MOTHERS AND MOTHERS-TO-BE
Is it possible to take public transport? Could you get off the bus a couple of stops earlier than you have to, park the car some distance from where you are going (or leave the car at home), take a walk during lunch? Consider your social activities. Could they be made more effortintensive? How and where do you see your family and friends? Usually we meet over food; this is fine, as it’s part of our culture to celebrate life events with food. But can you change this slightly so that, as in many European cultures, you meet friends for a walk (or ‘promenade’) and a coffee? Or plan a picnic where some walking is necessary instead of going to the movies. Look at your local area and find out where the parks and recreational areas are. Take the kids for a walk on weekends, fly a kite, teach them any kind of ball game, play with them yourself. There are endless possibilities. It all starts by hiding the remote control and getting out the front door (preferably leaving the car keys behind).
PLANNED ACTIVITY Planned movement for weight loss involves accumulating as much activity as possible. What is the minimum amount? Unfortunately, for women living in a modern industrialised society, it can be quite a lot. The US Weight Control Registry, for example, has found that in the modern environment a woman may need between 60 and 90 minutes of being active daily in order to lose weight, and up to 60 minutes just to maintain her weight. The good news is that this doesn’t have to be all in one go. How can you measure activity? One way is by recording the number of steps you take each day using a device called a digital pedometer, which is worn around the 22
New Mothers 15/5/03 11:24 AM Page 23
MORE MOVEMENT MAKES MIGHTIER MUMS
waist. As part of the full Professor Trim program you’ll receive one of these in your at-home weight loss kit. You’ll also be given a table to set your stepping rate to achieve weight loss at different levels. For the purposes of this Quick Start program, however, it’s important to say that any amount of walking will be helpful.
COUNTING STEPS A minimum level of 7500 steps a day just to maintain body weight will require about 60 minutes of an activity such as walking (extra to any activity which you normally carry out in your daily life). The good news is that it doesn’t have to be done at one time. For weight loss you can accumulate 5 lots of 1500 steps, or even 7500 lots of 1 step at a time. The main thing is that it is carried out. For best weight loss results, research has shown that women need more planned activity than men, amounting to around 80–90 minutes of accumulated activity a day. This would amount to over 10 000 steps, or walking a total of 4 or 5 kilometres, as well as regular daily activity. Because volume of physical activity is the issue here, however (where volume = frequency × intensity × duration), you may decrease the duration by increasing the intensity or frequency, if you are fit enough (at least before or after pregnancy; as you’ll see, we don’t recommend this during pregnancy). Doing an aerobics class, for example, at a relatively high level of intensity might help compensate for the time spent doing lower intensity activity, meaning that only 30 minutes a day could be enough (provided you don’t fall into the trap of being inactive the rest of the day to ‘compensate’). 23
New Mothers 15/5/03 11:24 AM Page 24
NEW MOTHERS AND MOTHERS-TO-BE
WHAT TYPE OF MOVEMENT? The best forms of weight loss activity are those which are weight-bearing, that is, where the body’s weight is not supported, as in the water or a on a bicycle. Some forms of movement are better than others. But in general we can say that it’s the weight-bearing activities, those where you have to carry your own body weight, that use up the most energy. These include simple, natural movements like walking. For the average person, walking is one of the best types of weight-loss activity, as in the average weight person it burns up roughly 1 kilocalorie for every 20–30 steps walked. It doesn’t matter whether this is in the form of a planned walk, going out to the shops, or just walking around the house or office. While walking should be the basis of all weight-loss activity, any form of movement is useful. However, as a pregnancy progresses National Physical Activity Guidelines
If you are able, also carry out some regular vigorous activity
3–4 days/week
Put together at least 30 mins of moderate intensity physical activity on most days
Most days
Be active every day in as many ways as you can
Daily
Think of movement as an opportunity, not an inconvenience
24
Always
New Mothers 15/5/03 11:24 AM Page 25
MORE MOVEMENT MAKES MIGHTIER MUMS
it may be necessary to do less weight-bearing activity and turn more to weight-supportive movements like cycling, swimming or aquarobics. Before and after pregnancy, the key is to carry out activities in line with the National Physical Activity Guidelines illustrated in the pyramid. During pregnancy, however, some changes may need to be made. The two guidelines at the bottom of the pyramid still apply, but the upper two, more active, guidelines need to be modified by the restrictions imposed by your physical condition. While putting together ‘at least 30 minutes of moderate intensity physical activity each day’ is feasible throughout pregnancy, the intensity of activity should be decreased as the pregnancy progresses. Small amounts of walking, however, can be accumulated right up to delivery without adverse effects. The top-level guideline, however, should be considered more carefully. If vigorous activity has been regularly carried out before pregnancy, there is little reason (given the provisos listed above), that this cannot be continued, although at a decreasing level and following medical advice, well into the pregnancy. However, it is not recommended for women who have not been regularly active before pregnancy to become so during pregnancy. Mild increases in movement at the level of the bottom three guidelines is unlikely to be harmful and will be helpful for long-term weight maintenance. Vigorous activity is not necessary except in mothers who wish to maintain a competitive level of sporting fitness, which is an area outside the scope of this booklet and requires specialised professional supervision.
25
New Mothers 15/5/03 11:24 AM Page 26
NEW MOTHERS AND MOTHERS-TO-BE
Professor Trim’s Prescription Pad • • • • •
• •
26
Move more for weight loss—as part of your daily lifestyle—even during pregnancy. Increase incidental exercise as much as possible. Carry out weight-bearing movement (e.g., walking) for weight management. Try to accumulate (put together) a minimum of 30 minutes of ‘planned’ activity a day. If possible try to accumulate at least 10 000 steps or 80 minutes of moderate intensity activity per day for best results—although not necessarily all at one time. If you are reasonably fit, the duration of activity can be decreased and intensity increased. Think of movement—any movement—as an opportunity and not an inconvenience.
New Mothers 15/5/03 11:24 AM Page 27
Chapter 4 STRESSING UP FOR (MORE) DINNER Stress is the third component, along with nutrition and physical activity, that needs to be considered in any weight management program for new mothers. At first glance, this may sound incongruous. Why stress? And what has this to do with weight control?
STRESS AND ENERGY BALANCE It’s not stress itself that is the issue. Indeed, stress can increase your metabolic rate, cause increased nervous fidgeting and result in other stress-related activities which can all help to burn energy and therefore fat. But in many people, women especially, it’s the reaction to stress that makes them gain weight—comfort-related eating in particular. If you’re like most women, you may well have been given food as a source of comfort whenever anything went wrong as a child. The general pattern goes: ‘There, there dear, everything will be all right. Here, have a lovely piece of cake (biscuit, chocolate, sweet . . .). That will make you feel better.’ If this happened to you as a child, it’s quite easy to understand why you’d tend to reach for the feedbag in adulthood when you’re faced with disruption to normal daily life. 27
New Mothers 15/5/03 11:24 AM Page 28
NEW MOTHERS AND MOTHERS-TO-BE
STRESS AND BINGE EATING For inveterate dieters, the situation is worse. Around 50 per cent of strict dieters, or ‘overly restrictive eaters’, are also binge eaters. That is, they not only eat when confronted by stress—they over-eat! Critical life events, such as marriage, divorce, job changes, childbirth, grief, and many other situations, can all lead to temporary stress and hence over-eating among binge eaters. If you react to stress in this way, learning new ways of coping with stress is important for you. If, on the other hand, you eat less and become more active when stressed, you have no real need to consider stress management for weight loss. But because chronic or extended stress in pregnancy can have an effect on birth outcome, you may want to know more about how to deal with it and thus increase your chances of a healthy pregnancy. Obviously in a short publication like this we can’t deal with the problem extensively. Here we provide the basics, so that if you are interested you can follow up on the topic in more detail, possibly through the full Professor Trim program for women, ‘Becoming Slimmer’.
WHAT IS STRESS ANYWAY? The term ‘stress’ is actually a misnomer because it implies a process rather than an outcome. In engineering terms a better word may be ‘strain’, or the effects of ongoing exposure to a stressor. Like strain on an engineering structure, stress will have little effect if the object being stressed is strong enough to withstand that stress. On the other hand, it can cause total collapse if the object of the stress is weaker than the severity of the stressor. 28
New Mothers 15/5/03 11:24 AM Page 29
STRESSING UP FOR (MORE) DINNER
A similar thing happens in people. Strain in this case has its effect on the psychological ‘structure’ of the individual, the ‘stressee’. If the capacity of the stressee is greater than the severity of the stressor, stress or strain is not an issue. In fact if the stressor is too weak it can even lead to boredom. If, on the other hand, the capacity of the person being stressed is less than the severity of the stress being applied, anxiety and its consequences (such as over-eating) are the outcome. The implications of this is that everyone has their own ‘red line’, above which stress becomes an issue. This may differ for different kinds of stressors. Your red line for stressors in the family, for example, such as your relationship with a partner, may be low, whereas your red line for work stresses may be much higher. The first lesson of stress management therefore is to recognise your own red line and try to keep just below it to get the benefits without the costs, in what American psychologist Mihaly Csikzentmihalyi calls the ‘flow channel’. You’ve probably heard this notion expressed in several different ways—for example: ‘If you can’t stand the heat, get out of the kitchen’, or ‘Don’t sweat the small stuff—and remember it’s all small stuff ’. Recognising your red line can help you go a long way to dealing with stress.
STRESS AND CONTROL The term stress is synonymous with ‘lack of perceived control’. If you think you have control of a situation, stress is unlikely to be an issue. Where you think you have lost control however (whether you actually have or not), stress can start to play havoc with your psyche. Again, if you are a typical dieter, or ‘overly restrained eater’, the 29
New Mothers 15/5/03 11:24 AM Page 30
NEW MOTHERS AND MOTHERS-TO-BE
reaction is likely to be to forget all this and binge—to make up for lost time! For this reason, dieting and inflexibility are the two worst characteristics for a person trying to maintain a good weight-loss program. Being too restrictive in your eating habits, and unable to cope with life’s little ups and downs, will shake the foundations of any weight-loss program to the point where over-eating—and consequent weight gain—become the rule rather than the exception. The key, then, is to regain ‘control’ over the situation— or at least ‘perceived control’. And this can only be done by instituting some form of ‘escape’, either physical or mental.
ESCAPE AND CONTROL Escape is often regarded as a negative way of dealing with a situation. It’s the coward’s way out. But in the sense in which we are talking here, escape is not only an effective solution, it’s possibly the only solution. Of course this doesn’t necessarily mean physical escape. While this may have been effective as part of the ‘fight or flight’ reaction used by our ancestors when faced with a frightening stressor, it’s not always the most effective option today. In the first place, it’s often not possible to physically flee an oppressive boss or a bad family situation. Most stress today comes not from an outside stressor but from our way of thinking about things. In this case escape doesn’t need to be physical—it can come through learning techniques of mental escape, such as meditation, negotiation and relaxation, as well as from physical approaches such as exercise or massage, or taking holidays. Finding the best type of escape to enable you to get 30
New Mothers 15/5/03 11:24 AM Page 31
STRESSING UP FOR (MORE) DINNER
through those critical periods which might otherwise lead to over-eating and inactivity is the key to managing stress. Recognising just what your stressors are and how they might be overcome is part of the solution.
Professor Trim’s Prescription Pad • • • • • • •
Beware of the effects of stress on over-eating. Become aware of your reaction to stress and the effects of this on your weight. Learn techniques to cope with ‘critical periods’ of stress. Try to stay under your stress ‘red line’. Recognise stress as resulting from a perceived lack of control. Attempt to regain perceived control where this is missing. Learn techniques of (physical and mental) ‘escape’ to restore control.
31
New Mothers 15/5/03 11:24 AM Page 32
New Mothers 15/5/03 11:24 AM Page 33
Part 2 Motherhood
New Mothers 15/5/03 11:24 AM Page 34
New Mothers 15/5/03 11:24 AM Page 35
PRE-PREGNANCY Chapter 5 WHEN WEIGHT GETS IN THE WAY For many women, conception and the process of pregnancy get under way without too much difficulty (and ideally, some enjoyment). It’s before this that long-term planning for weight management should begin, because not only can it be beneficial for lifetime weight management after giving birth, it can even help the process of getting pregnant in the first place. This is because body weight can greatly influence fertility. Most women know that if they are too thin (as can occur after a major illness, or in anorexia nervosa) their menstrual cycle can stop, leading to temporary infertility. This is an evolutionary mechanism that protects the mother. If there are insufficient energy stores to support both the mother and a developing baby, it seems logical that the chances of reproduction be reduced so that the woman’s survival is not compromised. It’s less well known, however, that at the other end of the spectrum weight gain, or being overweight, can also interfere with the regularity of the menstrual cycle. The reasons for this are not entirely clear, but one possible 35
New Mothers 15/5/03 11:24 AM Page 36
NEW MOTHERS AND MOTHERS-TO-BE
cause is what is known as the polycystic ovaries syndrome, or PCOS.
WEIGHT GAIN, POLYCYSTIC OVARIES AND GESTATIONAL DIABETES PCOS refers to a condition where the ovaries contain multiple cysts. Their presence leads to irregular menstruation or a complete stop to the periods, acne or hair growth on the face, breasts or abdomen (hirsutism) and, in severe cases, high blood fat levels (such as cholesterol and triglycerides), high blood pressure (hypertension) and increased risk of diabetes, hypertension and heart disease in later life. PCOS requires diagnosis by a doctor and blood tests are usually required. Weight gain usually underlies the development of PCOS. If weight gain is substantial and PCOS severe, the menstrual cycle can stop altogether, which affects fertility and the chances of pregnancy. Studies have shown, however, that even a modest weight reduction of around 5 per cent of body weight can make the periods more regular and restore fertility. PCOS and excess weight going into a pregnancy also increase the chances of a woman developing a temporary form of diabetes known as gestational diabetes mellitus (GDM). Although GDM usually resolves itself after childbirth, both PCOS and GDM increase the risk of developing permanent diabetes later on. Up to 50 per cent of women with GDM are at risk of developing later diabetes, but this risk can be reduced with early planning, in particular to reduce body weight. In the presence of excess body weight and PCOS, the chances of becoming pregnant can be improved by some medications. The diabetes drug Metformin can help to 36
New Mothers 15/5/03 11:24 AM Page 37
WHEN WEIGHT GETS IN THE WAY
restart periods after PCOS. Its effects are significantly improved by weight reduction, no matter how modest. Another drug, Clomiphene, can induce the release of an egg for fertilisation in overweight women with PCOS, but again this works best if used with a program of modest weight loss. Planning for weight loss before planning for motherhood therefore makes good sense. The question is, what is the best way to do this?
MEASURING OVERWEIGHT In the first place it’s necessary to check whether you are indeed overweight. Many women regard themselves as overweight when they are really of normal weight. While not perfect, the best and simplest measure of overweight in women is the body mass index (BMI). This is taken by dividing your weight (in kilograms), by your height (in metres) squared. A 50 kg woman who is 1.5 metres tall, for example, would have a BMI of 50/1.52 = 50/2.25 = 22.2. The recommended pre-pregnancy BMI ratings are different for different ethnic groups, reflecting different body types. BMI: categories and recommendations Asian/Indian/ Aboriginal
Caucasian
Pacific Islander
Less than 18
Less than 19
Less than 22
Underweight (gain weight)
18–23
19–25
22–27.5
Ideal weight (maintain weight)
37
New Mothers 15/5/03 11:24 AM Page 38
NEW MOTHERS AND MOTHERS-TO-BE
BMI: categories and recommendations (continued) Asian/Indian/ Aboriginal
Caucasian
Pacific Islander
18–24
26–30
27.5–32
Overweight (lose weight if waist also large—see below)
More than 28
More than 30
More than 32 Obese (lose weight)
Note, however, that because BMI is a measure of body mass, it may discriminate against those women who are athletes with a high level of muscle, or those who are gynoid, or ‘pear-shaped’, with low levels of body fat. For this reason, waist circumference is used as a back-up measure of fat distribution. To measure waist circumference, place a tape measure around the waist at about the mid-point between the lowest rib and the top of the hip bone (the iliac crest). Recommended pre-pregnancy waist circumference measures for different ethnic groups are shown below. Waist circumference (cm): categories and recommendations Asian/Indian/ Aboriginal
Caucasian
Pacific Islander
Less than 80
Less than 90
Less than 100 Ideal (maintain
81–90
91–100
101–110
More than 91
101–110
101–110
waist) Overfat (lose waist) Obese (reduce fat)
38
New Mothers 15/5/03 11:24 AM Page 39
WHEN WEIGHT GETS IN THE WAY
PLANNING WEIGHT LOSS FOR PREGNANCY Obviously, where overweight is not an issue, weight loss does not need to be considered before planning a pregnancy. However knowledge of the processes for maintaining a steady weight remains important, and the information contained in the previous chapters should be taken into consideration for the future. Since being overweight in the pre-pregnancy phase is related to the difficulty of attaining a lower body weight after pregnancy, pre-pregnancy weight loss will not only help fertility but also reduce the risk of post-partum weight retention. A reasonable goal is to lose from 1 to 1.5 kg each month. If you are very overweight, your doctor will be able to guide you on the use of other therapies (such as special diets and possibly even anti-obesity drugs) and may enlist the assistance of a dietitian or obesity specialist. It is also important to increase all types of physical activity, not just by two or three episodes of exercise each week, but by walking to as many places as possible, getting away from the computer and television, taking the stairs instead of the lift, leaving the car at home and so on, as described in the previous chapter.
NUTRITIONAL REQUIREMENTS The nutritional requirements in the pre-conception stage vary little from those of healthy nutrition in general, with the possible exception of a folate supplement, to be taken in the three months before becoming pregnant. Folate is a micro nutrient essential for the development of healthy nerve tissue; it is contained in foods such as dark green leafy vegetables (such as spinach), legumes, liver, whole grains, yeast and wheat germ. Folate supplementation has 39
New Mothers 15/5/03 11:24 AM Page 40
NEW MOTHERS AND MOTHERS-TO-BE
been found to reduce the incidence of a crippling neural problem called spina bifida in the baby. Many processed foods are now being supplemented with folate, as it has been recognised that our increasingly processed diets lack this essential micronutrient. Other nutritional recommendations at this stage for women not needing to lose weight are: • Eat as wide a variety of foods as possible. • Increase the proportion of (low-fat) protein in the diet (e.g., beans, lentils, seafood and lean meats). • Decrease total fats, but particularly saturated fats from animal foods (see Chapter 2). • Maintain or increase calcium content through the consumption of low-fat dairy products, sardines, etc. • Maintain a relatively high intake of complex carbohydrate and fibre (i.e., 3 or 4 pieces of fruit and 4 or 5 serves of vegetables a day).
EXERCISE REQUIREMENTS At this stage it is wise to form an exercise habit which can be maintained throughout and after pregnancy. Carry out as much incidental activity (see Chapter 3) as possible, and build a daily planned activity session into your routine. The important thing here is to set up an exercise routine which will not need to be changed in type or intensity from pre-conception to pregnancy. If you have always exercised or played sport regularly, you should be able to continue doing so (with medical advice) well into your pregnancy. If, on the other hand, you have been inactive in the pre-conception stage, any increase in activity levels during pregnancy should be carefully controlled and monitored. 40
New Mothers 15/5/03 11:24 AM Page 41
WHEN WEIGHT GETS IN THE WAY
In women who exercise at extreme levels (e.g., marathon runners), fertility may be reduced. This is usually signalled by a loss of periods—amenorrhea—and highly trained athletes may need to reduce their training levels to improve their chances of conceiving. Obviously, a good level of fitness is the ideal state in which to begin a pregnancy. This should not only guarantee a good beginning body weight, but also help you maintain it throughout the pregnancy and beyond. Specific exercises such as abdominal crunches and stretching should be encouraged at this stage to prepare your body for later expansion. Most forms of activity will help decrease or maintain body weight, with increased volume of movement (i.e., 45–60 minutes of accumulated activity per day) being recommended for those needing to lose weight. Although not widely researched, it is thought that a high level of physical activity both before and during pregnancy also reduces the chances of gestational diabetes. For this reason, high levels of activity should be a priority for women who: • • • • •
have previously had gestational diabetes; have a history of diabetes in the family; have high fasting blood sugars; are overweight; or are otherwise inactive.
PELVIC FLOOR EXERCISES AND STRETCHING Recent research has shown that a reduction in the muscle tone of the pelvic floor region can occur even after a first birth. Poor pelvic muscle tone increases the chances 41
New Mothers 15/5/03 11:24 AM Page 42
NEW MOTHERS AND MOTHERS-TO-BE
of later incontinence which, in turn, can make it difficult to maintain an exercise program and therefore keep your weight down. Embarrassing leakages during exercise are common among up to 50 per cent of overweight women, leading to a ‘vicious cycle’ where inactivity leads to weight gain and weight gain makes the incontinence worse. Incorporating pelvic floor exercises in your exercise routine is therefore recommended from the pre-pregnancy stage to ensure good pelvic musculature in later life. These exercises are discussed in Chapter 6. Stretching exercises, through the full range of motion, should also be carried out regularly (preferably daily) to prepare the body for giving birth. Appropriate stretches are taught in most pre-pregnancy classes.
CONTRAINDICATIONS TO HIGHIMPACT EXERCISE IN PREGNANCY There are some situations in which exercise should not be carried out in pregnancy. ‘Absolute contraindications’ are conditions where no exercise is recommended. These should be discussed with your obstetrician. ‘Relative contraindications’ are conditions where the situation should be reviewed by an obstetrician before exercise is undertaken.
Absolute contraindications • • • • • • 42
A history of miscarriage Maternal heart disease Premature labour Multiple pregnancy (twins, etc.) Small-for-age baby in the uterus Incompetent cervix (softer and more open than normal)
New Mothers 15/5/03 11:24 AM Page 43
WHEN WEIGHT GETS IN THE WAY
• Pregnancy-induced high blood pressure • Venous thrombosis or pulmonary embolism • Ruptured membranes
Relative contraindications • • • • •
High blood pressure Anaemia Extreme overweight or underweight Extreme inactivity leading up to pregnancy History of bleeding during pregnancy
SUMMARY Pre-conception is a time at which patterns may be set for pregnancy and beyond. Going into pregnancy overweight can be a problem for conception, as well as later weight gain and retention. Developing the nutrition and exercise habits that lead to weight loss at this stage can help reduce the later weight gain and weight retention which may plague an already overweight woman.
Professor Trim’s Prescription Pad • • •
Recognise the association between PCOS, infertility and excess body fatness. Seek treatment for PCOS where necessary. If overweight is not an issue, maintain a healthy nutrition and exercise program.
43
New Mothers 15/5/03 11:24 AM Page 44
WEIGHT MANAGEMENT PROGRAM
•
• •
44
If overweight, try to reduce your weight by around 5 per cent before becoming pregnant to increase fertility and reduce the risk of maintaining excess weight after delivery. Begin pelvic floor exercises to reduce the risk of later incontinence problems. Keeping weight under control, keeping active and eating healthily can help reduce the risk of gestational diabetes and, in the long term, the risk of type 2 diabetes mellitus (adult-onset diabetes).
New Mothers 15/5/03 11:24 AM Page 45
PREGNANCY Chapter 6 A NATURAL PROCESS
One of the great misunderstandings of the industrial age is that pregnancy is a phase of human life which requires complex intervention. While this may be true in some rare instances, it is unlikely that humans would ever have evolved to their current level if it was true in general. Pregnancy and childbirth have been a constant throughout human history. That said, improvements in medical understanding and care have improved the chances of a healthy outcome for both mother and baby. The downside in that we have sometimes over-medicalised what is an otherwise natural human activity. ‘Wrapping a woman in cotton wool’ is possibly as contrary to the natural needs of a healthy pregnancy as is paying no attention to it at all. The ideal situation is to develop appropriate care to ensure the long-term health of the mother and of the newborn child. We must remember that in western cultures, however, the environment is vastly different to that in which humanity evolved, and brings new risks. Weight gain during pregnancy is a case in point. 45
New Mothers 15/5/03 11:24 AM Page 46
NEW MOTHERS AND MOTHERS-TO-BE
HOW MUCH WEIGHT GAIN IS WISE IN PREGNANCY? It used to be thought that a woman had to gain a substantial amount of weight during pregnancy irrespective of her pre-pregnancy weight. This came about largely because fewer women in earlier times were overweight. In modern western societies this is no longer the case, and it’s now thought that women who are substantially overweight before pregnancy may not need to gain as much as their leaner sisters. Recent thinking in Australia is that a 7 kg weight gain is enough for a healthy pregnancy. However, the weight and health of the newborn child are not compromised by lesser weight gain in women who are overweight, and it would seem illogical to suggest a greater weight gain in pregnancy, especially in already overweight women, if there is no physiological need for it. The current Australian recommendation for an obese or significantly overweight mother-to-be is a maximum weight gain of 6 kg during pregnancy. Women with a BMI over 35 may not need to put on any weight at all, provided a healthy nutrient intake is ensured, as they have all the energy reserves needed to get them through their pregnancy, and any extra gain is likely only to reduce their chances of losing weight after giving birth.
SHOULD AN OVERWEIGHT PREGNANT WOMAN ATTEMPT TO LOSE WEIGHT? While gaining excess weight in pregnancy can be a problem, this doesn’t mean that an overweight woman should actively try to lose weight during pregnancy. Any 46
New Mothers 15/5/03 11:24 AM Page 47
A NATURAL PROCESS
active program of weight loss (with the exception of maintaining a healthy food intake) should be ceased after becoming pregnant, and the woman’s weight should remain stable or increase marginally. Your family doctor or dietitian can specifically advise you in this regard. Under no circumstances should a pregnant woman undertake crash dieting, fasting or severe dietary restriction, or take anti-obesity drugs. If you have a weight problem and have become pregnant, it is important that you see an obstetrician who is also familiar with weight loss principles and practices, who understands the processes of weight gain and retention during and after pregnancy, to guide you on weight management during your pregnancy.
Case study Emma, aged 32, is planning to get pregnant. She has irregular periods and weighs 95 kg (BMI = 36). She starts on a healthy eating and physical activity program. After losing 7 kg, she starts a regular menstrual cycle and falls pregnant after two cycles. She follows a very careful lifestyle program throughout her pregnancy, being aware of not over-eating and maintaining her activity levels. She has a normal delivery at 39 weeks, with a healthy baby girl weighing 3.4 kg. She gains a total of 10 kg in her pregnancy and, shortly after delivery, begins a more vigorous lifestyle program while aiming to breastfeed for as long as possible.
47
New Mothers 15/5/03 11:24 AM Page 48
NEW MOTHERS AND MOTHERS-TO-BE
THE PHASES OF PREGNANCY Pregnancy is a very special incubation period during which the female body undergoes a metamorphosis to cater for the developing baby’s needs and its own requirements. It is helpful to consider the process in the three stages of pregnancy, called ‘trimesters’, each approximately 13 weeks long.
FIRST TRIMESTER: WEEKS 1–13 In the first trimester, there may be few detectable physical changes, though for some women the symptoms can be very obvious. Many women will experience morning sickness, which usually (hopefully) is over by the time the second trimester rolls around. For most, however, the first trimester is otherwise a time of wellness. Oestrogen levels will start to climb, and some women will experience tenderness, fullness or heaviness of the breasts. Overall, there should be minimal weight gain during this time and physical activity should not be greatly altered, although hunger will increase markedly. Try to respond to hunger sensibly, bearing in mind the ease with which over-eating can occur in our modern environment. It is vital at this stage that sufficient food is eaten to satisfy the rapid early developmental needs of the baby, but it is also vital that genuine hunger is not confused with learned appetite. Women who have been strict, inflexible dieters are particularly vulnerable here, with a tendency to use the ‘excuse’ of pregnancy to binge eat. Eating regularly to avoid excessive hunger can prevent this. Because of the potential dangers from over-heating for the foetus in the early stages of development, it is important to avoid exercising in hot conditions (that is, over about 25°C) without adequate ventilation, or 48
New Mothers 15/5/03 11:24 AM Page 49
A NATURAL PROCESS
without regular fluid replacement. Sweating is not an indication of core body temperature during pregnancy and should not be used as a benchmark for over-heating.
Pelvic floor exercises Pelvic floor exercises to prevent later incontinence problems should be commenced in this phase of the pregnancy and continued throughout. There are two forms of the exercise: 1. A prolonged isometric contraction of the pelvic floor muscles, as if holding a pencil or other object in the vagina over an extended period; 2. Shorter, more dynamic, contractions and releases. Sets of 5–10 contractions of both forms of the exercise should be carried out each day. Where an incontinence problem develops during the pregnancy, a physiotherapist can be consulted.
Other exercises Other exercise requirements, which apply throughout the pregnancy, are: • check with your doctor for any contraindications to exercise; • avoid exercise which raises the heart rate to more than around 140 beats per minute; • spend a good ten minutes warming up and cooling down before commencing full exercise; • reduce the intensity of stretching, and don’t overstretch, which can put pressure on certain joints which become unstable during pregnancy; • wear loose, well-ventilated clothing; • avoid saunas and steam baths, which can cause over-heating; and • do not do full sit-ups at any time. 49
New Mothers 15/5/03 11:24 AM Page 50
NEW MOTHERS AND MOTHERS-TO-BE
When to stop exercising Exercising should be stopped if any of the following symptoms are experienced at any time during pregnancy: • extreme high body temperature; • faintness, dizziness or shortness of breath; • palpitations, blurred vision or severe headache; • vaginal bleeding or excessive incontinence; • lower abdominal pain, cramping, back pain or pubic pain.
SECOND TRIMESTER: WEEKS 14–26 This is a phase of considerable physical change. Your baby and placenta are growing rapidly and placing increasing demands on your body’s circulation and metabolism. The volume of blood in the circulation increases and this increases the work of the heart, both in increasing the strength of each cardiac contraction and in increasing heart rate. This increased circulation and the effects of oestrogen contribute to the ‘glow’ of pregnancy. The high cardiac output of the second trimester also results in a higher body heat, which is why your partner will try to snuggle up to you on cold winter nights while you feel like throwing off the blankets. You may notice that you are starting to puff a bit more when performing physical activity or exercising. The key here is to perhaps slow down a little but to keep moving. The skin on your abdomen will start to feel tight, clothes won’t fit so well and you will gain some weight. This may be a time to look for comfortable maternity clothing that doesn’t limit your movements. It’s a good idea to look for clothes that are comfortable to exercise in too, not just for presentation or ‘discretion’. 50
New Mothers 15/5/03 11:24 AM Page 51
A NATURAL PROCESS
The intensity of exercise should be gradually decreased during this stage to account for the growing weight being carried. While most other sports are not contraindicated, body contact sports should be avoided from this stage because of the risk of acute injury. Weight-supportive exercises such as aquarobics, swimming, rowing and indoor cycling may begin to be substituted for more weight-bearing activities, although walking (particularly with the use of a maternity belt) is still recommended. Other exercise recommendations during the second trimester are: • avoid activities that involve a sudden change in posture (e.g., from lying to standing); • continue to avoid over-heating; • drink plenty of fluids; • eat a small amount of complex carbohydrate-rich foods before and after exercise; • avoid rapid directional changes in exercise; and • don’t increase activity levels above those carried out previously. The second trimester is a time when the developing baby starts to consume more of your body’s iron stores; an iron deficiency can develop if you aren’t keeping up with those iron supplements (discussed in Chapter 4). Iron deficiency can make you feel tired or fatigued and, if untreated, can result in anaemia. Iron is a crucial part of the machinery in the mitochondria, the furnaces or energy makers in all of your cells. Iron deficiency is not such a great idea in pregnancy, let alone at the start of motherhood: who wants to be anaemic or exhausted even before the end of sleep as you knew it? 51
New Mothers 15/5/03 11:24 AM Page 52
NEW MOTHERS AND MOTHERS-TO-BE
THIRD TRIMESTER: WEEKS 26–39 At this stage you may be feeling increasingly tired, due to the constant effort involved in carrying the weight of the baby and any additional weight gain. Keeping your fitness up is important, so keeping active is essential, even if the type or intensity of activity being carried out needs to change. Your breasts will probably increase in size, in preparation for feeding your baby, and you may need a maternity bra to accommodate these changes. Make sure any new bra fits comfortably and gives you good support, especially when exercising. Underwire bras, which can cut into the breasts, will have to be abandoned at this stage. You may now be experiencing the mild contractions called Braxton-Hicks contractions. These are a normal part of pregnancy and are preparing the uterus for the big job ahead. At this stage plenty of rest and sleep is vital. There will be busy days ahead and what can seem to be endless nights. By ensuring you have the best possible physical and mental strength (which will depend on whether this is pregnancy number 1, 2, 3, 4 . . .), you can make the delivery a positive and empowering experience. The intensity and duration of exercise at this stage should be decreased, with a shift to more weightsupportive exercises (e.g., walking in water, aquarobics, indoor cycling, using exercise machines) where possible. All exercise should be ceased if it makes you feel faint or giddy, and over-heating must definitely be avoided. A pregnancy belt can help hold the lower abdomen in a more comfortable position while walking.
52
New Mothers 15/5/03 11:24 AM Page 53
A NATURAL PROCESS
Professor Trim’s Prescription Pad • • • • • • • • • •
Try to gain an appropriate amount of weight during pregnancy. If you are overweight or obese, weight gain may not be necessary during pregnancy. Overweight or obese women should gain a maximum of 6 kg during pregnancy. Irrespective of your starting weight, weight loss should not be attempted during pregnancy. Start pelvic floor exercises early in the pregnancy. Do not exercise in pregnancy at a more intense level than you were exercising beforehand. Do not over-heat and remain well hydrated during exercise. Only carry out gentle stretching during the latter phases. Reduce the intensity of exercise as your pregnancy progresses. Change to more weight-supportive exercises as your pregnancy progresses.
53
New Mothers 15/5/03 11:24 AM Page 54
PREGNANCY Chapter 7 SPECIAL NUTRITIONAL REQUIREMENTS IN PREGNANCY We’ve pointed out that while a pregnant woman needs more food than she did before becoming pregnant, over-eating is common and can result in later weight problems. This requires close attention to both the type and the amount of food eaten. (Other issues and special nutritional requirement that need to be taken into consideration are covered in most pregnancy information books or consultations with your doctor and will not be discussed in detail here.) In this chapter we look at those nutritional issues which may have particular relevance to weight gain and weight maintenance for the new mother.
CRAVINGS Many women experience cravings for certain types of food when they are pregnant. Although these are perfectly natural, generally indicating the body’s requirements for certain nutrients, they should not be taken as a licence to 54
New Mothers 15/5/03 11:24 AM Page 55
SPECIAL NUTRITIONAL REQUIREMENTS
eat whatever you like. Just like over-consumption at any time, cravings can lead to excessive weight gain. Similarly, the notion of ‘eating for two’ often gives women who are otherwise restrained a reason for over-eating which is not justified. The women who are most at risk here are those who have been constantly restrained in their eating patterns, or have been strict dieters for most of their lives, for pregnancy gives them an excuse to lift the restraints and ‘make up’ for all those years of abstention. Special care therefore needs to be taken if you have been an overly restrained eater leading up to pregnancy.
SMOKING AND DRINKING During pregnancy the body’s biological imperatives come to the fore. Increased hunger levels and cravings for particular foods are the body’s way of ensuring adequate nutrition for the offspring. However, these mechanisms are not infallible—they can be thrown out of balance by learned habits and environmental influences. Smoking, for example, dampens hunger and reduces the desire to eat. The smoking mother is faced with a paradox. If she continues to smoke she may harm her baby—children of smoking mothers are at increased risk of later health problems. Quitting, on the other hand, increases the mother’s chances of weight gain and later weight retention but decreases the risk of her developing smokingrelated disease. Smokers who are planning their pregnancy need to be aware that the earlier they quit, before even becoming pregnant, the less weight gain and weight retention they are likely to face. More importantly, if they combine quitting smoking with a weight control program, it is more likely that they will both decrease their weight and successfully quit. For this reason quitting smoking 55
New Mothers 15/5/03 11:24 AM Page 56
NEW MOTHERS AND MOTHERS-TO-BE
and weight management should be pre-conception priorities for intending mothers. Consuming alcohol in excess is known to affect babies’ birthweight. Children of mothers who drink heavily during pregnancy are likely to get off to a poor start in life as their lower birth weight leaves them at risk of later health complications. While alcohol in itself may not significantly affect the body weight of the mother, it is advisable for the health of the child that the mother moderate or cease her consumption of alcohol.
THE ‘RIGHT’ DIET DURING PREGNANCY Although energy consumption through food intake may be increased by up to 25 per cent in lean mothers during pregnancy, a pregnant woman’s nutritional requirements are similar to those for a non-pregnant woman, with a few exceptions noted below.
FAT Because fat is important in developing neural systems it is sometimes believed that the proportion of fat in the diet should be increased in pregnancy. This may have been the case in times when fat was hard to come by, but is unlikely to be a problem in the modern environment. Pregnant women should keep their intake of saturated fats (mainly from animal sources) to less than 10 per cent of their total diet. This will normally require restricting the intake of full-cream dairy products, animal products, and coconut milks and creams. Some other types of fat, the monounsaturated and polyunsaturated fats, particularly those from seafoods and olive oil, can be increased in moderation. 56
New Mothers 15/5/03 11:24 AM Page 57
SPECIAL NUTRITIONAL REQUIREMENTS
SEAFOOD Recent research has shown the particular benefits of seafood not just for general health, but for a healthy pregnancy. Most seafoods contain oils called omega-3 fatty acids which are known to have blood-thinning and cardio-protective properties, both of which may be useful during the childbirth process. Seafood should always be eaten cooked (to prevent potential food poisoning problems), but preferably not cooked in oils or fats like butter or margarine, which counteract the positive effects of the omega-3 oils. If you don’t feel like seafood during your pregnancy (some women can’t stand the thought of it), you may be tempted to get the same benefits through taking fish oil capsules. However, there is little research at this stage to support their consumption in pregnancy. You should be aware that because there is so much money in fish oil capsules these days, some seafood processors are extracting the oils from tinned fish such as tuna and salmon to sell separately. In some cases these oils are replaced with vegetable oils which can interfere with the benefits of any remaining omega-3 oils in the fish. Olive or canola oils are OK, but other polyunsaturated oils can be counterproductive. In general, look for whole, fresh seafood, or seafood canned in spring water, brine or its own oil.
FOLATE Folate is a micronutrient that is essential to healthy nerve tissue. It is generally found in foods such as dark green leafy vegetables (such as spinach), legumes, liver, whole grains, yeast and wheat germ. Many processed foods are now being supplemented with folate, as it has been recognised that our increasingly processed diet is lacking 57
New Mothers 15/5/03 11:24 AM Page 58
NEW MOTHERS AND MOTHERS-TO-BE
in this essential micronutrient. Folate supplements have been found to reduce the incidence of a crippling neurological condition in infants called spina bifida caused by inadequate development of a part of the ‘neural tube’. For this same reason folate supplements of up to 100 mg/day are often recommended for up to three months before becoming pregnant even in women who do not have indications for a folate deficiency.
IRON Your iron requirements increase substantially in pregnancy, in part due to the increased demands of your changing body but also due to the drain caused by the developing foetus on maternal stores, particularly in the second and third trimesters. You will be advised to take an iron supplement after about 13 weeks’ pregnancy, preferably with a food that contains vitamin C, as this maximises iron absorption. To minimise calorie intake, this could be a glass of grapefruit juice (rather than orange juice). Alternatively, you could choose one of the iron supplements that has vitamin C as part of the supplement. Iron-rich foods, such as red meats, can be accompanied by lemon juice, as is traditional in some cultures. To maximise your iron intake you should avoid caffeine, as it decreases the absorption of the iron. Excessive iron intake can cause health problems, so it is important that your supplement is taken at the dosage level recommended by your doctor, not on the basis that if some is good more will be better.
CALCIUM Calcium is essential for healthy muscles and bones. The dietary calcium recommendation for a pregnant woman 58
New Mothers 15/5/03 11:24 AM Page 59
SPECIAL NUTRITIONAL REQUIREMENTS
is 1600 mg per day. Good sources of calcium include dairy products, tinned fish such as salmon, tuna and sardines, and broccoli. Some soy products are also calcium fortified. It may be difficult to achieve this level of intake through foods alone, especially when trying to avoid weight gain, and so a calcium supplement may be necessary. Inorganic calcium, the form found in supplements, is best absorbed if taken around the time of the evening meal. It is important to check the amount of calcium in a supplement, because it can vary from 100 to 1000 mg of elemental calcium per tablet depending on the brand.
Professor Trim’s Prescription Pad • • • • • • •
As in the pre-pregnancy period, cut back on saturated fats during pregnancy. Eat plenty of green leafy vegetables. Eat plenty of whole, cooked seafood. If eating canned seafood, choose those canned in spring water, brine or their own oils. Talk to your doctor about a folate supplement. Try to increase your iron intake through ironrich foods. Keep up dairy intake for calcium, but go for the low-fat versions.
59
New Mothers 15/5/03 11:24 AM Page 60
PREGNANCY Chapter 8 SPECIAL CONSIDERATIONS IN PREGNANCY Pregnancy can create special health needs in some women and for those women it is important to seek specialist medical advice throughout. There are some common problems, however, related to body weight and/or weight retention that all new mothers or mothersto-be should be aware of.
DIABETES IN PREGNANCY Gestational diabetes mellitus (GDM) is a condition where the blood sugar (glucose) level is elevated. This might be found during a special test called the glucose tolerance test which your obstetrician or GP may arrange at about week 28 if you are at risk of GDM (for example, your age, a family history of diabetes, a previous baby’s birthweight over 4 kg, obesity or certain ethnic backgrounds), or if glucose is found in your urine. Once your doctor establishes that you have GDM, the usual therapies are to control the amounts of carbohydrate and fats in your diet, and to undertake regular 60
New Mothers 15/5/03 11:24 AM Page 61
SPECIAL CONSIDERATIONS IN PREGNANCY
physical activity, such as walking for at least 20 minutes every day. Sometimes, if glucose levels are not controlled by these methods, it may be necessary to start insulin therapy. Regular activity and a healthy diet, however, can generally decrease the risk of GDM occurring, and even reduce the severity of the condition when it does develop.
GDM and weight management If you have GDM and have a weight problem, further weight gain must be carefully controlled. In these circumstances, it is essential to work closely with your doctor and with the dietitian from the diabetes centre you attend. If you feel you are losing the battle, you must put your hand up for help immediately. GDM in pregnancy increases the risk of developing type 2 (adult onset) diabetes mellitus later in life. In fact around 50 per cent of GDM cases go on to suffer later type 2 diabetes. To reduce the risk of this happening, you will need to try to lose all of the weight you gained in pregnancy and keep it off for life. If you were overweight to start with, it would be ideal if you could lose weight to a level of about 5 kg below your pre-pregnancy weight. Overweight people mistakenly believe that they need to lose a very large amount of weight for health, but this is not true. Studies have shown that modest weight reductions (say 5 kg), even in very overweight or obese people, reduce the risks for diabetes, heart disease, high blood pressure and high blood fat levels (such as cholesterol and triglycerides). Do not be afraid to ask for help in weight reduction after the baby is born if you have had GDM. It is at this time especially that ‘a stitch in time saves nine’. 61
New Mothers 15/5/03 11:24 AM Page 62
NEW MOTHERS AND MOTHERS-TO-BE
HIGH BLOOD PRESSURE (HYPERTENSION) IN PREGNANCY High blood pressure in pregnancy is known by a number of names, including pregnancy-associated hypertension and pre-eclampsia. Women who are overweight can be at higher risk of hypertension in pregnancy and need to have their blood pressure monitored at each antenatal visit. If hypertension develops it would be prudent to try to keep any further weight gain down to the minimum. After the pregnancy, weight reduction to below the pre-pregnancy weight is important, again for life, to try and prevent the development of hypertension in later life.
UNDER-ACTIVE THYROID GLAND Most people are aware that an under-active thyroid gland can promote weight gain. The thyroid gland may be under-active for different reasons, such as having part of it surgically removed or, most commonly in women, because of an auto-immune condition called Hashimoto’s disease. The appropriate treatment of an under-active thyroid is replacement of the missing thyroid hormones, usually with thyroxine. The high oestrogen levels in pregnancy can place an added strain on the thyroid, as high oestrogen levels in turn increase the levels of a special protein that binds and inactivates thyroid hormones (called thyroid binding globulin). This means that women taking thyroxine for any reason may need to take a higher dose in pregnancy. Thyroid hormones need monitoring closely in pregnancy by your doctor and the thyroxine dose may require adjusting by your doctor from time to time. Under no circumstances should you experiment with your thyroxine dose without medical supervision. 62
New Mothers 15/5/03 11:24 AM Page 63
SPECIAL CONSIDERATIONS IN PREGNANCY
If weight gain is excessive in pregnancy and you feel very tired and lethargic, experience hair loss, feel cold constantly and have constipation, discuss this with your doctor. An under-active thyroid can present itself in or after pregnancy, sometimes due to an inflammation in the gland called thyroiditis. While this condition may require thyroid hormone replacement, it is often only temporary. Again, there is no place for self-diagnosis here: see your doctor and ask for advice.
PREGNANCY IN THE ‘PRIME OF LIFE’ Women have always had babies well into their late thirties and into their forties. Prior to contraception, this was the norm. Nowadays, however, we are seeing more and more women having their first child in this age bracket. As long as you are healthy, there are no special problems associated with the process of pregnancy; the risks relate predominantly to genetic conditions, which you should discuss with your doctor. It is as important to exercise and follow a healthy, balanced diet at this age, the ‘prime of one’s life’, as at any other time. Enjoy it, this is a very special time.
SPECIAL CONSIDERATIONS FOR THE SINGLE WOMAN If you ever thought being a mother couldn’t get any more difficult, spare a thought for those women who are making the journey on their own, that is, who are flying solo either through choice or circumstance. These are brave women. Single women have a number of special issues to tackle: they may have no one to share the night feeds 63
New Mothers 15/5/03 11:24 AM Page 64
WEIGHT MANAGEMENT PROGRAM
with, no one to stay with the baby while they pop outside to hang the washing/have a walk/take a bath. Many single mothers work, so their time is even more constrained: they have to compress the activities involved in caring for their children and themselves into the small number of hours outside work time. These women need to be doubly organised: they need to know who is available to help and when. It helps to have a wide circle of family and friends who can be enlisted to help with home duties/care duties and infant supervision when necessary.
Professor Trim’s Prescription Pad • • • •
64
Check blood sugars if there is a history of diabetes or diabetes symptoms. Reduce weight to reduce blood pressure in pregnancy. Check symptoms of thyroid deficiency with your doctor. Know who can help and when.
New Mothers 15/5/03 11:24 AM Page 65
POST-PARTUM Chapter 9 WEIGHT MANAGEMENT AFTER CHILDBIRTH
Weight gain is the expected process during pregnancy. Weight loss after childbirth—typically back to the prepregnancy level—is the ideal. In modern societies, however, this is happening less and less frequently. Why should this be the case? A casual glance at women living a subsistence existence, as well as knowledge of women’s body weight in the past, suggests that postpregnancy weight gain or retention is not the norm, thus implicating something—or everything—in the modern environment. As pointed out earlier, post-pregnancy weight retention is known to be influenced by a number of factors, including: • • • • • •
pre-pregnancy weight; extent of weight gain in pregnancy; quickness of return to work after pregnancy; early return to physical activity; number of pregnancies; and socio-economic status. 65
New Mothers 15/5/03 11:24 AM Page 66
NEW MOTHERS AND MOTHERS-TO-BE
A VICIOUS CYCLE OF WEIGHT GAIN Post-pregnancy weight gain can occur as the result of a vicious cycle, commencing with pregnancy weight gain and added to by the trauma of delivery, as demonstrated by this diagram. Because undertaking exercise activity at this stage is difficult, there is often a tendency to delay or postpone a return to pre-pregnancy activity levels. When this is coupled with unlimited increased food intake, and the often greater opportunities available to a nursing mother for snacking, the problem can become cyclical. The post-partum weight gain cycle Pregnancy
Increased weight
Increased opportunities for snacking
th bir ild h C
Increased fatigue and weight, post-partum
Decreased motivation/ opportunity to become active
The fact that women of higher socio-economic status have less long-term weight problems related to pregnancy suggests that the problem is lifestyle-based rather than physiological. And while the research evidence for this is, as yet, incomplete, a look at the lifestyle habits of this group of women could yield valuable information relating to long-term weight maintenance. 66
New Mothers 15/5/03 11:24 AM Page 67
WEIGHT MANAGEMENT AFTER CHILDBIRTH
Of course you might be tempted to go for a ‘magic pill’ or quick weight loss ‘diet’ or fast, and there are several of these around which offer ‘help’ to the vulnerable. However these methods of weight control are not only illusory but also potentially counter-productive. Fad ‘dieting’, fasting or skipping meals may lead to shortterm weight loss, but they also lead to longer term weight gains that are much harder to lose. We’ve been concentrating here on the key lifestyle and behavioural factors that can help you get rid of your excess post-pregnancy weight and keep it off for life.
EARLY RETURN TO PHYSICAL ACTIVITY Historically, women have been required to become physically active as soon as possible after childbirth. In traditional societies this does not seem to have had a significant ‘bad’ influence on either the mother or the child. Yet in recent times there is a tendency to confine the feeding mother as much as possible in order to guarantee the ‘quality’ and ‘quantity’ of breast milk. Notions about the influence of activity levels on breast-feeding have been vastly exaggerated. Recent research suggests that an early return to exercise affects neither the quality not quantity of breast milk. It does, however, help the feeding mother regain an energy balance which makes weight loss after pregnancy, and weight maintenance over the long term, more possible. There is no hard and fast rule about when you should return to exercise. Depending on the trauma of the delivery and the recovery process, some weight-supportive activity, such as walking, can be commenced within the first two weeks after childbirth. More vigorous activity and a return to regular exercise, as discussed in Chapter 3, can 67
New Mothers 15/5/03 11:24 AM Page 68
NEW MOTHERS AND MOTHERS-TO-BE
be commenced as recovery conditions dictate. However, the sooner this occurs, the less likely the chances of postpartum weight retention.
APPROPRIATE ACTIVITY One of the major difficulties after childbirth is finding opportunities to exercise. The chances are greater when you have a cooperative partner, although the problems of lack of sleep, fatigue and time availability may still remain. The situation can be improved by making the most of the situation in all or some of the following ways: • Make the most of a pram or stroller in the early days and months to increase walking. • Use a baby backpack to increase effort as soon as the baby can support its own head. • Participate in mothers’ groups that involve active leisure. • Enquire about childcare facilities in local exercise and recreation centres. • Take time out for personal exercise space where possible. • Walk as much as possible rather than use the car.
BREAST-FEEDING Although breast-feeding is promoted for the health of the child, there have been suggestions that breast-feeding is also effective in reducing the body weight of the mother. Unfortunately this belief is not backed up by the scientific research, which reports studies both for and against. However, no studies to date have used breast-feeding as an educational ‘window of opportunity’ (or ‘WOOPsie’) for weight loss. 68
New Mothers 15/5/03 11:24 AM Page 69
WEIGHT MANAGEMENT AFTER CHILDBIRTH
Because breast-feeding requires 500–700 kcals of energy per day, a lactating mother can eat up to 500–700 kcals more than a non-lactating mother and still maintain her body weight. Food intake which is unrestricted and exceeds this amount will result in gradual weight gain. If, on the other hand, a breast-feeding mother restricts her food intake to just below the requirement for energy balance (that is, under 500 kcals a day more than usual), a gradual loss of the extra weight gained during pregnancy should result. Provided food is not overly restricted (which would be difficult in the face of biological increases in hunger), this will not interfere with breast milk quality or quantity. Breast milk is a highly nutritious, high energy drink for babies, and a means of using up energy stored in a woman’s body as fat. Direct breast-feeding is one way for a woman to use up body fat; expressing breast milk for use (within 24 hours), or up to three months later (if frozen in sterile plastic containers) is another. There are a number of pumps that can be used to provide food for baby for the future, and thus assist in removing energy stores from the body. Ask your midwife at the hospital about them.
REDUCED FAT INTAKE Despite popular belief, there is no extra requirement for dietary fat for breast-feeding above that which is provided in a standard western diet. Indeed, fat intake is usually higher that that which is needed, thus adding to total energy intake and hence the likelihood of extra stored body fat. As in pregnancy, the types of fats which should be restricted most are saturated fats from animal foods. Some 69
New Mothers 15/5/03 11:24 AM Page 70
NEW MOTHERS AND MOTHERS-TO-BE
polyunsaturated and monounsaturated fats like those in seafood, olive and canola oils, can usefully be increased in the diet. Control of fat intake will make the reduction of total energy easier, and to this end the procedures for reducing dietary fat listed in Chapter 2 should still be followed.
SELF-MONITORING Self-monitoring is known to be one of the best practices among people who are successful at weight loss and weight loss maintenance. Monitoring should be not only of the outcome (that is, the weight lost) but also of process (that is, the exercise completed, the amount of fat eaten daily, and so on). Monitoring should be done on a daily or weekly basis.
Professor Trim’s Prescription Pad • • • • • •
70
Beware of the vicious cycle of weight gain which can occur after childbirth. Become active again as soon as possible after delivery. Carry out appropriate activities depending on your circumstances. Use breast-feeding as a ‘window of opportunity’ (WOOPsie) for weight loss. Maintain a low-fat eating program. Monitor process measures for weight loss as well as outcomes.
New Mothers 15/5/03 11:24 AM Page 71
POST-PARTUM Chapter 10 MYTHS ASSOCIATED WITH PREGNANCY AND BODY WEIGHT From reading this booklet you should have become aware of a number of unhelpful myths concerning pregnancy, childbirth and body weight in new mothers and mothersto-be. A number of them are summarised here.
MYTH 1: NATURE WILL ENSURE A RETURN TO PRE-PREGNANCY BODY WEIGHT AFTER DELIVERY Nature may do this in an environment where nature rules. However, in the modern obesity-promoting environment there are many temptations that make a return to normal body weight difficult without some form of conscious effort. Research indicates that for many women today, pregnancy and childbirth represent critical periods for weight gain which are difficult to reverse or stabilise. For others, motherhood provides an opportunity to reduce fat stores which have been difficult to shift until this time. 71
New Mothers 15/5/03 11:24 AM Page 72
NEW MOTHERS AND MOTHERS-TO-BE
MYTH 2: EXERCISE CAN REDUCE THE ABILITY TO BREAST-FEED Several research studies have shown no deterioration in the quality or quantity of breast milk, or the ability to breast-feed, as a result of an early return to physical activity after childbirth. While this may not be true in the case of excessive exercise, there is no reason for new mothers to be concerned about the health of their breast milk as a result of moderate levels of physical activity.
MYTH 3: BREAST-FEEDING MOTHERS NEED MORE FAT IN THEIR DIET While dietary fat is important for the development of neural tissue in the neonate, there is enough fat in even a fat-reduced modern diet to deal with this need. Monounsaturated and polyunsaturated fats provide the greatest benefit, hence at least some of these (e.g., from seafood, olive oil, canola oil) can be maintained; saturated fats (from animal foods and fast foods) should be decreased.
MYTH 4: BREAST-FEEDING PROVIDES NO BENEFITS FOR THE MOTHER There is now no doubt about the benefits of breast-feeding for babies. Some studies even indicate that breast-fed babies have less chance of becoming obese later in life than bottle-fed babies. Research examining the health of the mother, on the other hand, is not so definite. One study has found that mothers who breast-feed for six months or longer are able to keep their body weight lower for up to two years after feeding than those who do not breast-feed. Other studies have not supported this finding. The key to benefits for the mother appears to be 72
New Mothers 15/5/03 11:24 AM Page 73
MYTHS ASSOCIATED WITH PREGNANCY
her ability to consciously control food intake below the rate of energy use for breast-feeding. Being aware of not over-consuming, as well as being active at the time of feeding, could be the controlling factors in post-partum weight maintenance.
MYTH 5: SMOKING WILL NOT AFFECT POST-PREGNANCY BODY WEIGHT Smoking will keep body weight down (in fact, it could keep it down forever—in the cemetery!). Smoking in pregnancy, however, is not only disastrous for the immediate health of the mother and the baby, it is a potential time bomb for weight gain in both. It increases health risks in a number of major areas, and redistributes fat in women from the lower body to the more dangerous abdominal or truncal region. In addition, on quitting smoking there is a ‘bounce back’ effect of weight gain, which may last for several years, making proper longterm weight maintenance extremely difficult. Finally, smoking can influence breast milk and lead to early addiction and weight gain in the offspring after weaning—a similar effect to that created in an adult by quitting. As if this were not enough, the offspring of mothers who smoked through pregnancy have been found to have a greater chance of becoming obese and of contracting diabetes later in life.
MYTH 6: A PREGNANT MOTHER SHOULD BE ‘EATING FOR TWO’ Increases in hunger are normal for a pregnant woman, but the weight gain necessary for a healthy childbirth is not large, and may in fact be less than the average gain 73
New Mothers 15/5/03 11:24 AM Page 74
NEW MOTHERS AND MOTHERS-TO-BE
now seen in most modern western women. Although a 12 kg weight gain is now recommended for a woman of normal weight in the USA, the amount was previously 7 kg, and there is little evidence to suggest that the figure should have been changed. In a woman who is overweight or obese going into pregnancy, no weight gain may be necessary for a healthy delivery. Eating for two (full-grown people) is therefore an exaggeration that provides licence for many otherwise rigidly dieting women to over-eat during pregnancy, thus making later weight problems an issue.
MYTH 7: A PREGNANT MOTHER SHOULD NOT EXERCISE VIGOROUSLY While there are certain contraindications to exercise in some women (see Chapter 5), most women will benefit from a program of regular physical activity, albeit at a decreasing rate, throughout pregnancy. The intensity of exercise in the early stages of pregnancy will be determined largely by the extent of pre-pregnancy activity carried out by the pregnant woman. A woman who is very active may be able to maintain a high level of activity, with a doctor’s supervision, well into a pregnancy. Inactive women, on the other hand, should not be encouraged to become vigorously active during pregnancy. With all women, the amount, intensity and type of exercise will change with the progression of the pregnancy and according to individual requirements.
MYTH 8: ‘CRAVINGS’ ARE ALWAYS HEALTHY AND SHOULD BE ACTED ON Again, this may be true in a traditional hunter-gatherer environment. However, cravings can develop in the modern 74
New Mothers 15/5/03 11:24 AM Page 75
MYTHS ASSOCIATED WITH PREGNANCY
environment as a result of external rather than internal factors. Advertising, food availability, social pressures, work stress and a range of other factors can lead to the desire for particular types of foods. These are not genuine ‘cravings’ but conditioned desires which, if acted on, can significantly influence energy balance to tip the scales in favour of weight gain.
MYTH 9: THE MORE WEIGHT GAINED IN PREGNANCY THE BETTER The fallacy of this should by now be obvious. While weight gain in the normal weight woman may be a necessary part of pregnancy, it does not have to be excessive. Indeed, the greater the weight gain above that required for a normal healthy pregnancy, the greater the difficulty in returning to a healthy post-partum weight. This is not a recommendation for dieting or other attempts at weight loss during pregnancy. On the contrary, weight loss during pregnancy should be strictly avoided. A conscious awareness of the extent of weight gain, however, may help limit it and thus reduce later problems of body weight maintenance in a new mother.
MYTH 10: AN EXPECTANT MOTHER SHOULD BE ‘WRAPPED IN COTTON WOOL’ Women have been successfully giving birth since the beginnings of human time. They didn’t need expensive gynaecologists and machines that go ‘ping’ to help them do this. And while there have been huge advances in modern medicine which improve the chances of a healthy delivery, the notion that pregnancy is a time of extreme 75
New Mothers 15/5/03 11:24 AM Page 76
NEW MOTHERS AND MOTHERS-TO-BE
caution is based on an over-medicalisation of the condition. This is particularly so in indigenous and developing cultures, where weight gain in itself is a significant health issue. Mothers who have traditionally been active and vital during pregnancy are often confined and overprotected because of a misinterpretation of western medical science. This can create problems which are greater than those which modern medical science has solved.
SUMMARY As you should have gathered throughout the course of this book, a different emphasis is emerging in our understanding of healthy childbirth. Not only is it important that the health of the baby be guaranteed, but the longterm health of the mother should also be considered. Because permanent weight gain after pregnancy is a common occurrence in the modern environment, and because it can adversely affect the health of the mother, all efforts should be made to prevent it happening. It is to be hoped that the methods discussed in this booklet go some way to correcting this and some of the more common myths that have built up in recent years around the culture of childbirth.
76
New Mothers 15/5/03 11:24 AM Page 77
APPENDIX: PURCHASING PROFESSOR TRIM’S MEDICALLY SUPERVISED WEIGHT-LOSS PROGRAMS Professor Trim’s is a series of medically supervised weight loss programs with (a) minimal supervision (‘Quick Start’) programs for: • • •
families; new mothers and mothers-to-be; and people with diabetes or high blood sugars;
(b) medium supervision programs over 3–12 months for: • •
men (‘Becoming Gut Less’); and women (‘Becoming Slimmer’);
and (c) intensive supervision programs for: •
the long-term and very overweight.
All programs can be carried out at home alone, or on a shared care basis with your local GP and (if required) a fully qualified personal weight coach (PWC). 77
New Mothers 15/5/03 11:24 AM Page 78
NEW MOTHERS AND MOTHERS-TO-BE
Professor Trim’s Programs Of fer • • • • • •
A balanced, medically supervised approach to weight loss. No diets, tricks, fads, gimmicks—just up-tothe-minute scientific sense. Individualised care. Concentration on long-term maintenance, not just short-term losses. Twelve months’ care and supervision with the PT team and your GP. Toll-free advice as needed.
For more information or to purchase a Professor Trim’s medium or intensive supervision program, visit the Website on www.professortrim.com or ring toll free on 1300 708 300.
78
