Obesity; The Health Impacts And Relationship With Reproduction

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Obesity; The Health Impacts And Relationship With Reproduction


Abstract


Obesity is a leading preventable cause of death worldwide, with increasing prevalence in adults and children, and authorities view it as one of the most serious public health problems of the 21st century. Obesity negatively impacts the health of women in many ways, such as higher risk of low back pain and knee Osteasthritis. Also, obesity negatively affect both contraception and fertility. This study determined the health impacts of obesity and its relationship with reproduction. Data obtained by self- administered questionnaire, medical examination and anthropometric measurement of 578 pregnant women at different ages and trimesters was analysed using SPSS version 15. The result showed that 143 (25%) of the women were in the first trimester of pregnancy, 206(36%) were in second trimester while 229 (39%) were in the third trimester. The women were between the ages of 15-40 years while the mean ages of the women in years were 28.86+5.26, 28.11+4.29 and 28.39+4.20 respectively in the first , second and third trimesters.

There was no significant difference in the ages of the three groups (f= 1.44,p=0.32). The mean mid upper arm circumference (MUAC) and calf circumference(CC) in centimetre the first, second and third trimesters were 30.47±3.88, 30.23±4.02, 30.15±4.81and 36.81±3.50, 36.83±3.43 and 37.06±3.85 respectively with no significance difference (p=0.74,0.75). The mean waist circumferences were 92.31±10.78, 97.58±10.78 and 106.46±12.00 for the first, second and third trimesters respectively with a significant difference (p=0.001) The mean waist to hip ratios were 0.88±0.06,0.92±0.06 and 0.98±0.08 for the first, second and third trimesters respectively with significant 0.92±0.06 (p=0.001 ). All the parameters had positive correlation with BMI. Using the 75th percentile of MUAC and CC (33cm and 39cm) in all trimesters , MUAC and CC were shown to have a sensitivity and specificity more than 70% when using the estimated pre-pregnancy weight as gold standards . Waist and waist to hip ratio increased as pregnancy increased hence there may be need for various cut off point as gestational age increased. These indices may be invaluable tools for identification of obesity in pregnancy.


Table Of Contents


Preliminary Page(s)

  • Title
  • Declaration
  • Approval
  • Dedication
  • Acknowledgement
  • Abstract
  • Table of Content

Chapter One

Introduction

  • 1.1 Background of the study
  • 1.2 Statement of the study
  • 1.3 Aim and Objectives

Chapter Two

Literature Review

  • 2.1 The prevalence of obesity in pregnancy
  • 2.2 Effects of Obesity on pregnancy
  • 2.3 Anthropometric indices that can be used to identify obesity

Chapter Three

Methodology

  • 3.1 Study area
  • 3.2 Sample size
  • 3.3 Subjects
  • 3.4 Inclusion Criteria
  • 3.5 Exclusion criteria
  • 3.6 Equipments
  • 3.7 Data collection
  • 3.8 Data analysis

Chapter Four

Results and Discussion

  • 4.1 Some Demographic Characteristics Of The Study Groups
  • 4.2 Anthropometric Indices of the Different Study Groups
  • 4.3 Identifying Obesity Using The 75th Percentile Of MUAC,CC And Waist Circumference

Chapter Five

Summary Of Findings, Conclusion and Recommendation

  • 5.1 Summary of findings
  • 5.2 Waist Circumference and Waist to Hip Ratio in Pregnancy
  • 5.3 Using Other Anthropometric Indices to Identify Obesity In Pregnancy
  • 5.4 Anthropometric Indices, Age and Gravidity
  • 5.5 Limitations of the study
  • 5.6 Prospects for further studies
  • 5.7 Conclusion
  • 5.8 Recommendation
  • References
  • Appendix

Chapter One


Introduction

1.1 Background of the study

Obesity has been identified as a major risk factor for poor pregnancy out come. (Galtier et al., 2000; CMACE/RCOG 2010). It is most commonly defined as Body Mass Index (BMI) of greater than 30kilograms per square of height in meters (Galtieret al., 2000; CMACE/RCOG 2010). This definition is the same in both pregnant and non pregnant population (CMACE/RCOG 2010). For the pregnant woman, weight and height of the woman at first booking are obtained and the BMI calculated (CMACE/RCOG 2010). There are three different classes of obesity: BMI 30.0–34.9 (Class I); BMI 35.0–39.9 (Class 2); and BMI 40 and over (Class 3 or morbid obesity),(NICE 2006;WHO 2000). It is recognised that there is a continuous relationship between BMI and maternal morbidity and mortality (WHO2000).
Calculation of the body mass index requires the use of standard weighing scales and stadiometers and mathematical calculations by well trained personnel. These requirements may be lacking especially in developing societies such as ours.

The prevalence of obesity in pregnancy has continued to increase as its prevalence in the general public continues to rise. It has become necessary that adequate and non sophisticated methods of discovering obesity in pregnancy be identified in order to institute adequate management that will forestall poor outcome of the pregnancy.


1.2 Statement of the study

The use of body mass index in identifying obesity in pregnancy may not be a sensitive and specific criterion. This is because in pregnancy, there is an additional weight gain due to the presence of the foetus and placenta (Campbell and Lees 2000; Ganong 2005). There is also an increase in size of maternal organs such as the breast and the uterus (Campbell and Lees 2000). There may also be accumulation of fluid in the extra cellular spaces in pregnancy which would increase the weight of the woman (Campbell and Lees 2000). Moreover the lordosis which occurs in pregnancy is normally associated with a decrease in height of the woman (Scholl et al., 1990; Hirabayaet al., 1997).

There may even be an increase in height of adolescent mothers in pregnancy even though this may be very small. (Scholl et al., 1990) Appropriate management of women with maternal obesity can only be possible with consistent identification of those women who are at risk (CMACE/RCOG 2010). The NICE Antenatal Care guideline (2008) recommends that maternal height and weight should be recorded for all women at the initial booking visit (ideally by 10 weeks gestation) to allow the calculation of BMI. It is common knowledge that very few women book at 10 weeks; even in developed countries (Heslehurtet al.,2007).

The measurement of the Mid Upper Arm , Hip, Waist and Calf Circumferences can be taken at very low cost requiring neither the expensive and sophisticated equipment nor mathematical calculations hence may prove to be invaluable in assessing pregnant women especially in developing societies.

These measurements can be taken while standing, sitting or lying making assessment of the sick woman who is unable to stand easy (Collins 1996). Therefore a study like this which would identify the normal range for these anthropometric indices – Mid Upper arm, Waist, Hip and Calf Circumference, is necessary in order to identity those who are well above the normal hence obese and at risk of obesity related conditions.


1.3 Aim and Objectives

1.3.1 Aim

To identify some anthropometric indices that can be used to identify obesity in pregnancy

1.3.2 Specific Objectives
  1. To measure some Anthropometric indices –Weight, Height, Mid Arm, Calf ,Waist and Hip circumferences in pregnant women at different
    trimesters.
  2. iTo identify the relationship between Body Mass Index and the circumferences of the Mid Arm, Calf, waist and the Hip at different trimester.
  3. To identify the normal limit of these indices at different trimesters of pregnancy.

Chapter Five


Summary Of Findings, Conclusion And Recommendation

5.1 Summary of findings

Anthropometric measurements taken in the antenatal period have been used to predict increased risk of gestational diabetes, preeclampsia, eclampsia, foetal macrosomia, post-term delivery, and caesarean section which are associated with obesity in pregnancy (Wendland et al., 2002; Satteret al., 2001). Different cut off points have been given by studies done in various countries for some of these parameters in order to identify women at poor outcome of pregnancy. In this study, cross sections of pregnant women living in Enugu were studied to ascertain how these parameters could be used to identify obese pregnant women in our environment.


5.1 Demographic characteristics of the study groups

The mean age of the women used in this study was approximately 28±3.45 years. Majority of the women that participated in the study were in the 25-29 age group. Globally, there is an upward trend in maternal age at first pregnancy increasing from approximately 21 years in the 1970’s to 27 in this decade(Chapman et al, 2006, Hendrick, 2009, Laws and Sullivan, 2005.). Globally, there is an upwards trend in maternal age with age at first pregnancy increasing from approximately 21 years in the 1970’s to 27 in this last decade(Chapman et al, 2006, Hendrick, 2009, Laws and Sullivan, 2005). These changes can be traced to the interest of women being more in careers and financial security than child bearing (Bachrach, 2006). As seen in this study, less than one-fifth of the women in the study were occupied with non-paid domestic duties. The rest were either full time students, self employed or had paid duties outside the home. This agrees with the perspective of Bachrach, (2006).


5.2 Anthropometric Indices and Pregnancy:

Anthropometric indices such as weight, height are used commonly in pregnancy to assess the pregnant women. Mid upper arm circumference, Calf circumference, waist circumference and hip circumference are less commonly used.

5.2.1 Body Mass Index and Pregnancy

Body mass index is the commonest criteria for identifying obesity in pregnancy, calculated by weight in kilograms divided by the square of height in metres (CMACE/RCOG 2010).

From this study the mean weight (in kilograms) was seen to progressively increase from the first to third trimester while the mean height remained the same. The progressive increase in weight being due to the increasing size of the baby and certain maternal organs such as the uterus and breast (Campbell and Lees 2000, Ganong 2005) .The mean Body Mass Index (BMI) was also seen to have increase in the same direction. Hence the use of BMI to identify obesity in pregnancy is not specific because weight increased as gestational age increased while height remained constant.

5.2.2 Mid Upper Arm Circumference and Pregnancy

Mid upper arm circumference has been seen to either remain constant throughout pregnancy in some countries or change as pregnancy progressed in other societies.

In this study, the mean Mid upper Arm Circumference values (in centimetres) in the first, second and third trimesters (30.47±3.88, 30.23±4.02 and 30.15±4.81) were higher than the 27± 3.44 cm found by Ricalde et al., (1998).

This difference may be accounted for by the fact that their study involved a smaller group of 97 women or that our women are predisposed to having larger arms than Brazilian women. It could also be that the current trend of obesity in pregnancy has affected women in Enugu since their study was done a decade ago.

MUAC from our study has excellent correlations with maternal weight but there was no significant difference in the three study group. This shows that it is independent of gestational age and this agree with previous studies done (Krasovec, 1989; Ricalde et al., 1998), hence it can be used to identify the size of the women regardless of the pregnancy.

5.2.3 Calf Circumference and Pregnancy

Calf Circumference has been studied less extensively in pregnancy than MUAC. In this study, also correlated with weight and BMI but not as much as MUAC and this agrees with Khadivzadehet al.,( 2002).

In this study there was no significant difference in the calf circumferences of the different study groups. Piperettaet al.,(2002) in their longitudinal study among pregnant women in Columbia and found a significant difference in calf circumferences between the second and third trimester women who gave birth to normal neonates. It may be that these women develop oedema later in pregnancy since those with oedema were excluded from this study. Calf circumference may therefore also be a pointer to the pre-pregnancy weight of the woman in our environment in the absence of leg oedema.

5.2.4 Waist Circumference and Waist to Hip Ratio in Pregnancy

Waist circumference and waist to hip ratio are measures of central adiposity used to predict adverse pregnancy outcomes. Various studies have tried to assign Cut off points of waist circumference for preeclampsia, gestational diabetes and dislipidaemia (Wendland et al.,2007, Yamamoto et al., 2001). In this study the mean waist circumference in the first trimester was 92.31±10.78cm. It is much higher than the 81.7± (7.7) cm found in Brazil by Wendland et al., (2007). This difference may be due to genetic and environmental differences in the study groups. Women in our society may be more predisposed to central obesity probably due to our diet which is mainly carbohydrate. In our study mean waist circumference increased significantly from first to second trimester, contrary to finding by Wendland et al., (2007) that waist circumference did not increase significantly until 28 weeks.
In all the trimesters, waist circumference correlated positively with weight and BMI. In order to use waist circumference to identify obesity in pregnancy in our environment, different cut off may be needed for different ranges of gestational age.

A hip circumference wider than the waist circumference is considered protective against adverse effects of obesity (Snijder et al.,2004). Hip Circumference was seen to increase significantly from first to third trimester. The mean hip circumference for first, second and third trimesters were 105.31±9.10 cm, 105.97cm±8.79 and 108.65±9.27cm respectively. This agrees with the finding of Piperattaet al., (2002) that women that had increase in hip circumference gave birth to normal birth weight neonates while reduction or static hip circumference was associated with low birth weight. The reason for the increase in hip circumference may be due to the effect of pregnancy hormones on the body.

In our study, waist circumference increased more than hip circumference hence the increase in mean WHR with mean values of 0.87±0.05, 0.92±0.06 and 0.98±0.08 respectively for the three trimesters. WHR ratio can be used to identify obesity in pregnancy if different cut offs points are given for different gestational age.


5.3 Using Other Anthropometric Indices to Identify Obesity In Pregnancy

Anthropometric indices other than weight and height may be very useful in identifying obesity in pregnancy. Pregnant woman with MUAC of ≥ 33cm is very likely to be obese and more so if the calf circumference is also greater than 39cm no matter the gestational age or the height of the woman. From this study, MUAC has a sensitivity of 76 % and a specificity of 91% while CC has a sensitivity of 78 % and a specificity of 85% when compared to the estimated prepregnancy weight. Waist circumference and Waist to Hip Ratio can also be used by identifying where the woman falls in a velocity curve depending on her Gestational age.

These measurements are easier to take and involve no mathematical calculations or costly equipments (Collins 1996). They are also less prone to errors than weighing scales. They may therefore be invaluable in identifying obesity in pregnancy in our environment where expensive equipments and man power may be constrains in recognizing women at poor pregnancy outcome due to obesity.


5.4 Anthropometric Indices, Age and Gravidity

From the study, the mean value of the anthropometric indices increased as the age of the women increased. Khadivzadeh T.( 2002) in his study of anthropometric indices in women of reproductive age also got similar results. Women tend to become obese with increase in age. Since gravidity increases with age of each woman, this may explain why those with higher gravidity also had increase in the mean values of the anthropometric indices. This may also mean that women in our environment do not shed all the pregnancy weight gain after delivery.


5.5 Limitations of the study

Some of the limitations of the study merit discussion. First, most women in our environment book in their second trimester hence it was difficult to get those in the first trimester. Secondly, attempts made to involve women living in rural areas failed because they were hardly present in health care centres provided for them at the hours for the study. Hence most of the women in this study live in the urban and sub urban areas.

Thirdly, the fact that the study is a cross sectional study makes it unable to identify changes in anthropometric indices of the same women as pregnancy progresses.

Fourthly, government hospitals could not be used because of industrial actions going on during the period of study.


5.6 Prospects for further studies

Further studies can be done with a much larger sample size to identify more effective cut off points for obesity in pregnancy. Longitudinal studies can also be done to identify how these indices change in individuals during pregnancy. Studies that show the possible outcome of pregnancy at different cut off points of indices can also be done. These women can also be followed up to 6 weeks after delivery to ascertain the degree of pregnancy weight gain that was shedded.


5.7 Conclusion

The obesity in pregnancy is associated with poor pregnancy outcome for both the mother and the baby (Galtier et al., 2000; CMACE/RCOG, 2010). Body Mass Index used for identification of obesity in pregnancy is not a specific criterion.

Other indices such as Mid upper arm circumference, Calf circumference, waist circumference and Waist to Hip Ratio have positive correlation with weight can be used instead of BMI to identify obesity in pregnancy.

MUAC and CC from this study did not vary from trimester to trimester hence can be used to identify obesity no matter the gestational age of the woman. Cut off points of 33 cm and 39 cm can be used to identify obesity.
Waist circumference and Waist to Hip Ratio increased in pregnancy and can be used to identify obesity if velocity curves are used.

Anthropometric indices increased as age and gravidity showing that obesity may be associated with increase in age and gravidity.


5.8 Recommendation

First, in order to reduce the incidence of maternal mortality and morbidity in our environment, our women should be educated on the need for antenatal care and early booking.

Secondly, adoption of other anthropometric indices other than weight and height for recognizing obesity in pregnancy will ensure that a greater number of women who are obese are identified and proper management instituted for them. Moreover, tapes with color codes showing normal and abnormal circumference ranges can be provided in clinics and healthcare centers for identifying obesity in pregnancy.


Obesity; The Health Impacts And Relationship With Reproduction


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