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Obesity in Pregnancy: Maternal and Neonatal Effects medigraphic Artemisaen línea Janet C. King and E. Casanueva Perinatol Reprod Hum 2007; 21: 210-217 Obesity in Pregnancy: Maternal and neonatal effects JANET C. KING,a ESTHER CASANUEVAb ABSTRACT In the 21st Century, obesity has become a world-wide epidemic. In Mexico, about 75% of non-pregnant women of reproductive age (between 20-49 years of age) are overweight or obese (body mass index > 25). In the USA, over 60% are overweight or obese. Overweight and obese women are more likely to gain excessively during pregnancy, and they are more likely to maintain excess weight after delivery. This weight gain also has implications for the child’s future risk of being overweight. In this paper, we will review the impact of maternal adiposity on reproduction, the effect of obesity on maternal metabolism and complications in pregnancy, the short and long-term effects on the infant, and potential interventions for alleviating poor outcomes. KEY WORDS: Overweight, obesity, pregnancy, adiposity. INTRODUCTION word leptos, meaning thin) concentration diminishes Overweight and obese women are more likely to in animals receiving an hypoenergetic diet. This de- gain excessively during pregnancy, and they are more crease induces neuroendocrine changes that affect likely to maintain excess weight after delivery.1 This reproductive performance. When leptin is injected weight gain also has implications for the child’s future into these animals and they recover their fat depots, risk of being overweight.2 neuronedocrine and reproductive changes are quickly reverted.3 Actually, body fat is an important modula- IMPORTANCE OF MATERNAL BODY tor of reproductive performance. It has been re- FAT FOR REPRODUCTION ported that after stratifying women by Body Mass In 1980, Rose Frisch hypothesized that a minimum Index (BMI), the highest reproductive efficiency is amount of body fat is necessary for the appearance of found in those with a BMI between 20 and 25 while menarche. This hypothesis was confirmed by Ahima women with extreme values of BMI (< 20 and > 25) less than ten years ago after performing a series of diminish their reproductive performance. elegant studies showing that the plasma leptin (hor- In normal conditions, water explains 53% of mone excreted by the adipose tissue, responsible of women’s body weight and fat represents between 26 some of the mechanisms involved in regulating the and 28% of their weight; almost twice as high as the appetite and whose name is derived from the Greek percentage of men who have 14% of fat and 61% of water. Due to the above-mentioned differences females have a higher tendency to accumulate body fat. This predisposition is the result of a metabolic a Childrens Hospital Okland, Research Institute (CHORI), Uni- versity of California, Davis. Correo electrónico: adaptation directed towards ensuring first hominids’ [email protected] survival even in conditions of food shortage.4 b Instituto Nacional de Perinatología Isidro Espinosa de los Reyes. México. In this context, it is convenient to remember that Recibido: 06 de noviembre de 2007. the most efficient way of storing energy is through the Aceptado: 30 de noviembre de 2007. fat deposition; due to its hydrophobic characteristics, 210 VOL. 21 No. 4; OCTUBRE-DICIEMBRE 2007 Perinatol Reprod Hum Obesity in Pregnancy: Maternal and neonatal effects one kilogram of fat cells contain around 800 mg of sion, glucose intolerance, and dyslipidemia.15 The triacyl glycerides that provide around 72000 kcal. normal metabolic adjustments of pregnancy make Therefore, in normal conditions, women’s fat stores the obese woman especially prone to develop hyper- are more than enough to cover gestational energy tension and its related metabolic disorder, preec- needs, breastfeeding and newborn’s fat deposition. lampsia, and glucose intolerance and its related meta- Actually, human newborns have higher fat storage bolic disorder, gestational diabetes mellitus. The (around 14% of their body weight) than the rest of the degree of maternal adiposity and risk for these meta- primates, who are born with 3% of fat. bolic complications are related; the higher body As mentioned before, fat reserves gave females an weight, the greater the risk.16 The risk for gestational evolutionary advantage very useful under food depri- diabetes ranges from 2 to 8-fold higher than that of vation conditions, like those occurred several mil- normal weight women as the body weight of the lions of years ago, when the climatic changes forced woman increases from overweight to severely obese.17 hominids to adapt in order to live in the savanna A similar trend exists for preeclampsia; the risk is where food was hardly available. As a matter of fact, about 2-fold higher in overweight women and 3-fold several Paleolithic figurines of fertility goddess, dated higher in obese women compared to normal weight 35 millions of years old, show silhouettes of women women.11,17 Preeclampsia is more common in women with evident obesity. However, currently we are living with gestational diabetes than in non-diabetic women in an environment with an overabundance of energy suggesting related underlying biological aberrations. dense foods that together with a sedentary lifestyle, Tight blood glucose control during pregnancy lowers are leading to an excessive fat storage and, conse- the risk for preeclampsia in women with gestational quently, the increasing of chronic diseases.5 diabetes.11 The risk for gestational diabetes rises during preg- Maternal obesity, infertility, nancy because the peripheral tissue sensitivity to and early pregnancy loss insulin declines by about 50 to 60 percent in late Menstrual disorders and infertility are common pregnancy presumably to limit maternal glucose use problems of obese women.6 It is estimated that 25 and to conserve it for fetal growth and development. percent of ovulatory infertility in the United States is Since insulin also inhibits lipolysis, when insulin sen- attributable to overweight and obesity.7 Because adi- sitivity declines in pregnancy, the breakdown of stored pose tissue synthesizes estrogen, obese women have triglycerides occurs and fatty acids are released into higher levels of endogenous estrogen compared to circulation. It is thought that the insulin resistance of non-obese women, which increases the risk for ir- pregnancy is mediated by placental hormones and regular menstrual cycles and infertility.8 It is not cytokines.18,19 The decline in insulin sensitivity during uncommon for infertility specialists to advise mor- gestation is greater in obese than in normal weight bidly obese women to lose weight before beginning women. Possibly, an increased level of with fertility treatments. proinflammatory cytokines produced by the excess Obese pregnant women also experience higher adipose tissue in obese women contributes to their rates of spontaneous abortions or early pregnancy increased risk for glucose intolerance. Serum C-reac- losses,3,9-11 The risk of spontaneous abortion is about tive protein levels, a marker of inflammation, have 20% higher in obese than in normal BMI women.12 been correlated with the body mass index of women in Spontaneous abortion rates are also higher in over- late pregnancy.20 weight women after in vitro fertilization than in lean In the past, women with gestational diabetes were women (22% versus 12%).13 The risk of infertility and prescribed diets providing about 1200 to 1800 kcal/d.21 early pregnancy loss can be reduced if obese women These low calorie diet improved maternal glucose lose weight prior to conception.14 tolerance and reduced fetal overgrowth. However, a concern about maternal ketosis with the severe en- Maternal obesity and metabolic ergy restriction and potential impaired fetal complications during pregnancy neurodevelopment caused a shift from severe energy In non-pregnant adults, obesity is associated with restriction to carbohydrate restriction.22 In 2004, the the metabolic syndrome, characterized by hyperten- amount of carbohydrate recommended for pregnant VOL. 21 No. 4; OCTUBRE-DICIEMBRE 2007 Perinatol Reprod Hum 211 Janet C. King and E. Casanueva women with gestational diabetes has been increased placenta blood supply leading to preeclampsia. A from 45 to 65% of the energy, with an emphasis on Cochrane Review of 12 high-quality calcium supple- whole grains and high fiber foods.23 Studies by Fraser mentation trials showed that providing calcium supple- et al.,24,25 Clapp et al.,26,27 and Zhang et al.,28 have all ments to women with low intakes reduced the inci- shown that lowering the glycemic load while increas- dence of preeclampsia by about one-half, and no ing cereal fiber is an efficacious way to reduce the risk adverse effects were observed. However, there is no of gestational diabetes or glucose intolerance in evidence that calcium supplementation reduces the women during pregnancy. The type of dietary fat risk of preeclampsia in women with adequate calcium consumed may also influence the risk of developing intakes. Sodium restriction and calorie restricted di- glucose intolerance during pregnancy. Diets low in ets have also been used to treat preeclampsia, but polyunsaturated fatty acids and high in saturated fat there is little evidence that those treatments are appear to increase the rise of hyperglycemia of preg- effective.33,37 nancy.29,30 Research has also shown that moderate, Other complications that occur more frequently in consistent physical activity throughout gestation obese pregnant women include insufficient
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