Obesity and Women's Reproductive Health
Menstrual Function and Fertility
Obesity in premenopausal women is associated with menstrual irregularity and amenorrhea (112, 116). As part of the Nurses' Health Study, a case control study suggested that the greater the BMI at age 18 years, even at levels lower than those considered obese, the greater the risk of subsequent ovulatory infertility (117). The most prominent condition associated with abdominal obesity is polycystic ovarian syndrome (118), a combination of infertility, menstrual disturbances, hirsutism, abdominal hyperandrogenism, and anovulation. This syndrome is strongly associated with hyperinsulinemia and insulin resistance (119).
Pregnancy can result in excessive weight gain and retention. The 1988 National Maternal and Infant Survey observed that 41.6 percent of women reported retaining 9 lb of their gained weight during pregnancy, with 33.8 percent reporting 14 lb of retained weight gain (120). The retained weight gain associated with pregnancy was corroborated by the study of Coronary Artery Risk Development in Young Adults (CARDIA). As a result of their first pregnancy, both black and white young women had a sustained weight gain of 2 to 3 kg (4.4 to 6.6 lb) of body weight (121).
Another study on a national cohort of women followed for 10 years reported that weight gain associated with childbearing ranged from 1.7 kg (3.7 lb) for those having one live birth during the study to 2.2 kg (4.9 lb) for those having three (178). In addition, higher prepregnancy weights have been shown to increase the risk of late fetal deaths (179).
Obesity during pregnancy is associated with increased morbidity for both the mother and the child. A tenfold increase in the prevalence of hypertension and a 10 percent incidence of gestational diabetes have been reported in obese pregnant women (122). Obesity also is associated with difficulties in managing labor and delivery, leading to a higher rate of induction and primary Caesarean section. Risks associated with anesthesia are higher in obese women, as there is greater tendency toward hypoxemia and greater technical difficulty in administering local or general anesthesia (123). Finally, obesity during pregnancy is associated with an increased risk of congenital malformations, particularly of neural tube defects (123).
A certain amount of weight gain during pregnancy is desirable. The fetus itself, expanded blood volume, uterine enlargement, breast tissue growth, and other products of conception generate an estimated 13 to 17 lb of extra weight. Weight gain beyond this, however, is predominantly maternal adipose tissue. It is this fat tissue that, in large measure, accounts for the postpartum retention of weight gained during pregnancy. In turn, this retention reflects a postpartum energy balance that does not lead to catabolism of the gained adipose tissue. In part, this may reflect reduced energy expenditure through decreased physical activity, even while caring for young children, but it may also reflect retention of the pattern of increased caloric intake acquired during pregnancy (180).
One difficulty in developing recommendations of optimal weight gain during pregnancy relates to the health of the infants. A balance must be achieved between high-birth-weight infants who may pose problems during delivery and who may face a higher rate of Caesarean sections and low-birth-weight infants who face a higher infant mortality rate (181). However, data from the Pregnancy Nutrition Surveillance System from CDC showed that very overweight women would benefit from a reduced weight gain during pregnancy to help reduce the risk for high-birth-weight infants (181).
The 1990 Institute of Medicine report made recommendations concerning maternal weight gain (182). It recommended that each woman have her BMI measured and recorded at the time of entry into prenatal care. For women with a BMI of less than 20, the target weight gain should be 0.5 kg (1.1 lb) of weight gain per week during the second and third trimester. For a woman whose BMI is greater than 26, the weight gain target is 0.3 kg (0.7 lb) per week during the last two trimesters.
Women who are overweight or obese at the onset of pregnancy are advised to gain less total weight during the pregnancy (182).
Weight Gain During Pregnancy