Annual Meeting & Conference

Gwinnett Technical College

Welcome!

October 4, 2016

HEALTHY MOTHERS, HEALTHY BABIES

Coalition of GeorgiaEst. 1973

Our mission is to improve access to healthcare for Georgia's

women and children through advocacy, education and

access to vital resources.

Obesity: Breaking the Cycle

with BreastfeedingSusan Boekel, RD, LD, IBCLC

Outpatient/Wellness Dietitian

susan.boekel@athenshealth.org

Objectives

• Participants will be to:

– State 2 ways to measure obesity

– Explain the impact of Obesity on fertility, pregnancy outcomes, lactation and infant feeding practices

– Discuss lactation support needed for obese women

– Describe how obesity can be stopped at any age

Life is a Cycle

– Decisions that Impact the Prevalence of Obesity • Breastfeeding• Introduction of Solids• Lifestyle Habits and Role Modeling• Weight Status during Pregnancy in Georgia

– Nearly 56% pregnant women are overweight or obese

– 48.5% of pregnant women gain in excess of IOM guidelines

– Maternal Metabolic Syndrome programs mitochondrial dysfunction over 3 generations

Infancy

Childhood

Adulthood

Pregnancy

Measuring Obesity

• Ideal body weight – Rule of 5’s and 6’s

• BMI- Adults and Kids– 18.5- 24.99 = “normal” or 5-84th%

– >25 = overweight or 85-94th%

– >30 = obese or 95-98th%

– >40 = morbid obesity or > 99th%

– >45 = super obesity

• Waist Circumference- 35” and 40”

Health Risks Related to Obesity

• Inflammatory Diseases- Adipose tissue produces inflammatory factors– Heart Disease/Heart Attacks– Hypertension/Stroke– Diabetes Mellitus/Kidney Damage, Blindness, Amputations,

Heart Attacks– Insulin Resistance– Arthritis and Joint Pain/Loss of Mobility– Cancer– Asthma– Obstructive Sleep Apnea– Infertility/Reproductive Complications

– Psychological Disturbances

Medical Treatment for Obesity

• Medications

– Appetite Suppressants/Stimulants

– Absorption/Digestion blockers

– Hormone Resistance/Antagonists

• Exogenous Insulin -satiety, fat storage

• Metformin and other oral hypoglycemic agents

• Exogenous Leptin- satiety, produced in adipose tissue

• Exogenous Adiponectin- sensitizes insulin response, produced in adipose tissue

• Others

– Resistin- increases insulin resistance= antagonist

– Ghrelin- appetite stimulant= antagonist

• Bariatric Surgery- Roux En Y, Lap Bands, Sleeves= restriction and/or malabsorption

• Lifestyle Changes (Wait for it!)

Obesity’s Impact on Women

• Fertility

– PCOS and androgens, Bariatric Surgery and nutrient deficiencies

• Prenatal

– IOM recommendations for prenatal weight gain-BMI 18.5-24.9= 25-35lbs, 25-29.9= 15-25lbs,>30= 11-20lbs

• Pregnancy Outcomes

– LGA, GDM, C/S, Pre-eclampsia & HTN, Longer labor

• Initiation of Lactation

– Decreased initiation and less exclusivity in hospital

• Duration of Lactation

– Delayed lactogenesis- decreased prolactin response to suckling, delayed 1st

feeding, increased stress to mom and baby, lack of confidence from decreased fullness, leptin inhibition of oxytocin/milk ejections

Note: there are some cultural differences in initiation and duration

Lactation Can Decrease Obesity

• Maternal Obesity– Desire to have a healthy baby– ~500-1000 kcal/d expenditure (lost from hips)

Note: risk of weaning if weight loss is not immediate

• Pediatric Obesity– Breastmilk calorie efficiency and absorption– Learning internal satiety cues from demand feeds– Introduction of flavors before beikost– Introduction of more fruits and vegetables during

weaningNote: some research inconclusive

Prenatal Lactation Support

• Prenatal preparation at 1st visit and with frequent follow up– Get accurate height and weight measures at

1st visit– Prevent XS prenatal weight gain by

encouraging lifestyle changes • exercise in 10-15 min increments up to 150

min/wk• 350-450 kcal increase only

– Begin Breastfeeding Education

Intrapartum Lactation Support

– Ambulation

– Frequent position changes

– Pain management without newborn sedation

Postpartum Lactation Support

– Limit/prevent separation- skin to skin and early feeding– Assist with latch- flat nipples, larger breasts

• Sandwich technique, pumping to form nipple, nipple shield with follow up

– Assess Latch – Position comfortably - large chairs or beds, rolled towels,

back support- no breasts on chests– Manage Engorgement- reverse pressure softening– Use Alternate massage- assist with milk transfer– Review expected stool output– If unable to latch- hand express and feed colostrum– If separated- begin pumping with massage using a hospital

grade double pump with proper education, assess breast shield fit and provide community resources

Additional Issues

• Post Bariatric Surgery- screen for B12 Deficiency in mom and FTT in infants; recommend a multivitamin and parenteral B12 for mom

• Intertrigo- Proper bra fitting w/non-synthetic, porous fabric, instruct to clean and dry breast folds daily, consider skin barrier creams or cornstarch, address secondary fungal or bacterial infections with appropriate agent

Discharge Planning

• Review feeding cues• Achieve comfortable, appropriate latch• Discuss feeding frequency and duration• Teach identification of infant swallow• Provide log for stools, urine, feeds and breast assessment• Offer contacts for WIC, LLL, and local LC’s• Recommend a healthy low fat diet and exercise after lactation

is established (see bibliography)• Plan frequent monitoring and follow up

Note: a lactation support groups for obese women has been effective

Lifestyle Habits to Support Healthy Weight for All

• Drink 8 cups of water a day

• Eat breakfast daily

• Eat a minimum of 5 fruits and vegetables a day

• Get 30 minutes of moderate activity (60 for kids) daily- cardio and weekly weight resistance

• Limit screen time to 2 hours a day

• Limit sweet drinks to 2 per week

• Limit eating out to 2 times a week

Diabetes Prevention Program

• Risk factors for pre-diabetes or type 2 diabetes, if you are overweight or obese or are over 45:

• Have a parent or sibling with DM• Are African American, Alaskan Native, American Indian, Asia

American, Hispanic, or Pacific Islander• Had a baby weighing over 9lbs or had GDM• Have HTN• Have an HDL <35 or TG >250• Have PCOS• Have impaired glucose intolerance or impaired fasting glucose• Have other conditions associated w/insulin resistance-severe

obesity or Acanthosis Nigricans• Have a history of cardiovascular disease

Bibliography

• Jevitt, C et al. Lactaton complicated by Overweight and Obesity: Supporting the Mother and Newborn. Journal of Midwifery & Women’s Health, Vol 52, No 6, Nov/Dec 2007.

• Position of the Academy of Nutrition and Dietetics: Nutrition and Lifestyle for a Healthy Pregnancy Outcome. JAND, July 2014, Vol 114, No 7.

• http://pediatrics.aappublications.org/content/early/2016/07/11/peds.2015-2388

• http://www.who.int/mediacentre/factsheets/fs394• http://www.who.int/mediacentre/factsheets/fs311

Bibliography

• http://www.who.int/end-childhood-obesity/facts• http://health.gov/dietaryguidelines/2015/guidelines/chap

ter-1/about/• http://health.gov/dietaryguidelines/2015/guidelines/appe

ndix-1/• Milano, K. How Infant Feeding transition Relate to Feeding

Difficulties in Young Children. PNPG Building Block for Life, Spring 2016, Vol 39, No 2.

• Rosen-Carole, C et al. ABM Clinical Protocol #19: Breastfeeding Promotion in the Prenatal Setting, Revision 2015. Breastfeeding Medicine, 2015, Vol 10, No 10.

Bibliography

• Saben, J et al. Maternal Metabolic Syndrome Programs Mitochondrial Dysfunction via Germline Changes across Three Generations. Cell Reports 16, 1-8, June 28, 2016.

• Centers for Disease Control and Prevention. Strategies to Prevent Obesity and Other Chronic Diseases: The CDC Guide to Strategies to Support Breastfeeding Mothers and Babies. Atlanta: U.S. Dept of health and Human Services; 2013.

• https://www.niddk.nih.gov/about-niddk/research-areas/diabetes/diabetes-prevention-program-dpp/Pages/default.aspx

• http://www.ncbi.nlm.nih.gov/pubmed/20821042

Bibliography

• http://www.ncbi.nlm.nih.gov/pubmed/20573792• http://www.ncbi.nlm.nih.gov/pubmed/22411371• https://stacks.cdc.gov/view/cdc/21456/Print• Katz, d. Feeding Our Kids, Kidding Ourselves. Childhood

Obesity, Oct 2013, Vol 9, No 5.• http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2784422/• https://www.babble.com/babble-voices/25-fitness-

weight-loss-products-you-wont-believe-exist-3/• http://www.nhlbi.nih.gov/health/educational/lose_wt/BMI

/bmicalc.htm