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Let them eat cake? Digesting the facts

28 November, 2014

Let them eat cake? Digesting the facts

The subject of weight is never easy to raise. But with obesity at an all-time high, midwives can’t afford to overlook it. Helen Bird finds out how, in approaching weight management sensitively, positive outcomes can be achieved.


Midwives and health visitors are crucial in the transmission of public health to mothers and new babies. They are vested with ensuring that the mental and physical health of mother and baby is optimised.’
While statements such as this one, taken from a newly published report by the Department for Culture, Media & Sport and the Government Equalities Office (Orbach and Rubin, 2014), provide midwives with a stark reminder of their public duty, in certain instances it is far easier said than done.
With obesity reaching disturbing new levels – it is thought that one in four UK adults is obese (Food and Agricultural Organization of the United Nations, 2013) – tackling it has become a matter of urgency. And, with a reported one in five women beginning pregnancy with a raised BMI (RCOG, 2011), the onus is on midwives now, more than ever, to help protect the health of this group and their unborn children.
The issue is a notoriously tricky one to raise, since it concerns not only health but physical appearance. But, sadly, it’s a conversation that midwives, as health professionals, can’t afford to avoid.
‘Obesity is a significant public health problem and we’re dealing with a population where levels are increasing,’ says Gail Johnson, RCM professional advisor for education. ‘Our members face a number of challenges in terms of raising awareness of what is a very difficult topic.’
It is on this basis that the RCM, in collaboration with Alliance partner Slimming World, has launched two new i-learn modules designed to guide and support midwives in doing exactly this. ‘The new modules centre around understanding the importance of weight and weight management, and how you might start a difficult conversation,’ says Gail. ‘They give hints on how you might approach the topic, in trying to make the woman feel more comfortable and to understand that the midwife is there to try and help, not to pass any kind of judgement.’
Indeed, it is the non-judgement element of caring for overweight and obese women that often extends beyond professional duty. Perhaps all too easily forgotten, on the part of the public in any case, is the fact that midwives, too, are human, and many are battling with their own weight issues. As if it were needed, this adds an additional element of difficulty to the ‘obesity’ conversation with women.
The new i-learn modules touch on this topic too, since many midwives in this position feel that they are perceived as hypocrites when providing healthy eating and lifestyle advice in a clinical setting and are thus even less comfortable raising the subject.
But, far from making women feel they are being preached to, showing empathy helps the interaction, says Carolyn Pallister, Slimming World’s public health manager. 
‘It is widely believed that women feel more comfortable having a conversation with someone who isn’t a size 10,’ she says.
‘We encourage midwives to use a bit of self-disclosure if they feel comfortable in that way. It can lead to a more open discussion,’ she adds.
One midwife who has brought personal experience to her practice is Emily Brace. As a student nurse, Emily felt so unhappy with her own excess weight that she lost just under six and a half stone, becoming Slimming World’s Diamond Member 2013. 
‘When I broach the subject with women, they probably look at me and think: “What would you know?” because I’m a size 10,’ she says. ‘But I can explain by putting my personal perspective on things and try to help them lead healthier lifestyles.
‘It’s got to be the woman that wants to do it primarily, but if I can help them to identify some of their areas of concern, which were also once mine, then they’re more likely to try and adopt change.’
Of course, once the conversation has been started, for most women, the prospect of putting themselves and their unborn babies at risk is reason enough to make the necessary changes to their diet and lifestyle.
‘Pregnancy is a big motivator,’ agrees Karen Jewell, who, as consultant midwife at Cardiff University Health Board, works in one of the UK’s most obese areas. ‘When you start talking about excess weight gain in pregnancy – that we know it’s linked to obesity in young children and teenagers and that they might get diabetes – that is the motivation.’
As senior clinical lead on the Healthy Eating and Lifestyle in Pregnancy (HELP) study, Karen has implemented care pathways to support obese pregnant women in managing their weight through physical activity and healthy eating. 
The study – a randomised controlled trial across 20 antenatal clinics in England and Wales – focused on whether such a programme is effective in reducing women’s BMI at 12 months from giving birth.
The results show that it helped women with their ability to control weight gain and ‘more babies were born in the healthy weight range to those women who lost weight during pregnancy’ (Jewell et al, 2014).
Karen tells Midwives about the approach taken for the care pathways. ‘We’ve trained our midwives in brief interventions,’ she says. ‘There are so many topics that you need to bring up in a short amount of time, so it’s important how you address it.
‘It’s very much about small steps. We normally find that the women come in at 22 weeks and they’ve gained weight. Then we have the conversation and hopefully put the brakes on a little bit, so that they don’t gain too much.’
It seems that the small steps approach, and communicating to women that nobody is expecting miracles is the key, as Ailsa McGiveron has found. 
Through the ‘Bumps and Beyond’ weight management service she implemented at Lincoln County Hospital with colleague Sally Foster, Ailsa has seen highly encouraging results.
‘We’ve found that 92% of the women that attend our service gain less than 9kg,’ she reports. ‘We’ve also reduced pre-eclampsia and blood pressure by 90% and postpartum haemorrhage by 43%, and if they attend our service, they’re 3.7 times more likely to breastfeed than non-attenders.’
The huge difference being made by the initiative, which the midwives set up in response to a growing number of women booking with a BMI of 30 or above, is clear to see. It also resulted in Ailsa and Sally being shortlisted for this year’s RCM awards in the Slimming World Award for Public Health category.
The fact that obesity is rising at such an alarming rate means that it sits at the top of the public health agenda. Recently issued NICE guidelines (2014) make 18 recommendations relating to the provision of weight management services to adults. 
However, obesity’s prevalence also means that people are starting to regard it as ‘the norm’, as Ailsa reports. ‘One woman I saw had a BMI of 51 and didn’t know what the problem was, because she thought she had a healthy diet. Another said: “Why are you picking on me? All my friends are the same size.”
‘If they start the pregnancy obese, they’re going to end it obese, but we can help so that they don’t put that extra four stone on, they may only put on a couple of kilograms and we can try to prevent the high blood pressure,’ she adds.
Of course, as with any serious health condition, the consequences of obesity extend beyond the physical. The government report, Two for the price of one: the impact of body image during pregnancy and after birth (Orbach and Rubin, 2014), explores the perhaps less considered, psychological and emotional effects of being overweight while pregnant and post-birth, and of an unhealthy relationship with food.
The report states: ‘The way [the woman] eats, her attitudes towards health, food and hunger, as well as the emotional reasons why she may eat or may not eat, are all passed on wordlessly to her baby: the positive and the negative.’
Psychologist Lisa Newson, who is pregnant at the time of speaking to Midwives, agrees that weight can be a highly emotional subject. ‘Women who have a weight issue prior to becoming pregnant are likely to be sensitive about it already, and they’ll become more aware of that during pregnancy,’ she says.
Unfortunately, the media often perpetuates women’s negative body image by glamorising female celebrities who lose their baby weight quickly, and criticising those who don’t. ‘The press creates this negative perception and it’s hard for women to feel that they’re doing it right,’ Lisa adds.
She also believes that better psychological support could be offered by midwives. ‘How they fit it in and how it’s delivered is a slightly different question,’ she says, ‘but there’s definitely a role for it because they’re the only professionals women see all the way through pregnancy.’
It certainly seems that, at this point, the best that midwives and other health professionals can hope to do is keep obesity at the top of the agenda. Some believe that a return to the old system of weighing women at every antenatal appointment would be a good way to achieve this. ‘That used to be the norm,’ says Ailsa. ‘You didn’t think you were being picked on.’
There also seems to be a consensus that clear UK guidelines on the ideal weight gain during pregnancy should be put in place. But equally, says Gail, each woman should be assessed on an individual basis: ‘There’s a challenge in sticking within a rigid weight range, because this refers to the average woman.’
While the modern obesity trend may never be completely reversed, midwives can contribute by providing support and guidance to those women that need it, helping them to take control for themselves and for future generations. The declining numbers on the scales will come as a result.

Raising the issue

Bringing up the topic of weight is never an easy task. Here are some key points to remember when broaching the subject with women:

  • Put yourself in her shoes. While weight is often a sensitive topic, the woman is likely to want you to bring it up and off er the support and guidance she needs.
  • Be aware of steps that may have already been taken. You might see a woman with excess weight in front of you, but she could have already lost weight and be feeling great about that.
  • Consider the language you use. If you need to weigh the woman, rather than telling her to get on the scales, say something like: ‘I need to update our records, would you mind if I weighed you today?’ Likewise, use ‘high BMI’ rather than ‘obese’.
  • Self-disclosure can go a long way. You may feel that you’re struggling with your own weight, but this needn’t be a barrier. Showing empathy and sharing your own experiences can help to break the ice and put the woman at ease.
  • Use the ‘drip-feed’ approach. Time is of the essence at booking but even one question, such as: ‘How are you getting on with eating and keeping active?’ keeps it on the agenda.
  • Be sensitive. Some women feel uncomfortable talking about their weight in front of their partner, for example. Try to clarify any sensitivities before you start the conversation.
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Food and Agricultural Organization of the United Nations. (2013) The state of food and agriculture.
Jewell K, Avery A, Barber J, Simpson S. (2014) The healthy eating and lifestyle in pregnancy (HELP) feasibility study. (accessed 18 November 2014). 
NICE. (2014) Managing overweight and obesity in adults – lifestyle weight management services. NICE guidelines [PH53]. (accessed 9 October 2014).
RCOG. (2011) Why your weight matters during pregnancy and after birth. (accessed 19 November 2014).