A note before I get started: I’m not laying blame on any mothers. I am laying blame on the old-yet-enduring hyperfocus on weight + the anti-fat bias in society and healthcare. As individuals, we’re all just trying to do the best we can, and when we look back on something we did that we thought was right at the time, but we now realize was perhaps wrong, that can be a gut punch that’s worthy of self-compassion, but also a resolve to do better now that we know better.
About a month ago, I was researching an article on the “wackadoo history of dieting” for my paid “Food Noise” newsletter, when I remembered something I heard a few years ago. Namely, that dieting mothers in the 1960s and 70s could be a contributor to the “ob*sity epidemic,” which emerged in this country in 1976-1980. Let’s look at what was going on in the previous two to three decades:
- 1962: Weight Watchers debuted
- 1963: Tab soda entered the market, to help you keep “tabs” on your weight. (Arrrgghhh…I remember drinking this as a CHILD!)
- 1966: Twiggy was the aesthetic ideal
- 1970s: BMI adopted as a tool to track and screen for ob*sity
- 1972: Publication of “Dr. Atkins Diet Revolution” and founding of NutriSystem
- 1976-1980: The concept of the “Ob*sity Epidemic emerged in the U.S.
- 1977: Slim Fast and Dexatrim entered the marketplace
- 1980s: First Jane Fonda Workout video
- 1981: Lean Cuisine entered the marketplace (and we all felt guilty when we weren’t satisfied by tiny portions of cardboard food)
Hmmmm…interesting
What happens in utero lingers for life
The idea of “eating for two” when pregnant has been around for ages, but that wording is a bit misleading. A pregnant adult doesn’t need to eat double their usual calories, but they do need to eat more calories and more of key nutrients. This is to support the developing fetus as well as meet the increased nutritional needs of their own body, which is growing more tissue and dramatically expanding blood volume to, you know, grow a human.
In fact exposure to inadequate calories and nutrients during critical windows of development — with the time in the womb being one of the most critical — is associated with disturbances to metabolism and behavior later in life. Data from observational research and animal research very strongly suggests that “nutritional programming” in utero can affect the health of the fetus from birth through death.
The most critical part of this “critical window” is at conception and eight weeks after. Why? Because that’s when the future child develops their organs. If organs don’t develop correctly because of inadequate calories and nutrients, then those organs are “trained” to function in a low-nutrient environment.
After birth, when the child and future adult have access to adequate calories and nutrients, there will be a permanent mismatch between the conditions in which the organs were formed and the conditions in which they continue to function. This sets the stage for chronic health conditions such as high blood pressure, type 2 diabetes, metabolic syndrome and chronic kidney disease. It also sets the stage for weight gain. (This is known as the Developmental Origins of Health and Disease.)
So, why am I mentioning observational studies and animal research, when randomized controlled trials are the only type of research that can truly establish cause-and-effect? Because it would be deeply, horribly unethical to randomly assign pregnant people to either eat an inadequate diet or an adequate diet.
However, we do, sadly, have data from real-world famines that approximate a randomized controlled trial.
What we learned from the tragic Dutch famine
For example, a wealth of valuable information came from the Dutch famine (also known as the Hunger Winter) in The Netherlands for six months at the end of World War II. The Nazis had cut off food supplies to the western part of The Netherlands, directly or indirectly affecting 4.5 million people.
The combination of an exceptionally harsh winter, bad crops, and four years of war meant the population in this area was forced to live on 400-800 calories per day. People had to eat grass and tulip bulbs to survive. (I remember reading Audrey Hepburn’s autobiography many years ago, and she talked about her experience living through this.)
Flash forward about 50 years, and researchers began studying the health of adults who were in utero during the famine, and compared that to the health of siblings who were in utero before or after the famine. They were able to do this because:
- There was a sudden onset and rapid relief from the famine (well defined time period).
- It was imposed on a previously well-nourished population.
- Food availability was registered accurately throughout the famine.
- Midwives and doctors continued to provide obstetric care and kept detailed medical records throughout the famine, some of which have been kept for decades – allowing long-term, follow-up studies.
They found that adults who were in utero during the famine—especially in the first trimester—were more likely to suffer from a variety of physical and mental health issues as adults, but adults exposed to famine at any point while in utero were more likely to develop type 2 diabetes and heart disease as adults. Exposed females also had a higher risk of breast cancer. They were also more likely to become “overweight,” and children of fathers who were exposed to famine in utero (so, the next generation) were more likely to be in higher-weight bodies as adults.
So this was famine. What does that have to do with dieting? Well, the body doesn’t know the difference between a famine and intentional calorie-restriction, and there were some crazy-ass restrictive diets in the 1960s and 1970s. And if a woman was on one of these crazy-ass diets at the time of conception, and remained on that crazy-ass diet for weeks before she knew she was pregnant, what might that have done to her child? (Again, not laying blame on the mothers!!!)
Smaller babies, larger adults?
Regardless of the reason, poor nutrition and inadequate weight gain during pregnancy is associated with increased risk of pre-term birth and newborns that are small for gestational age. This is true regardless of where on the BMI chart the mother’s weight falls when she becomes pregnant. (Not that I think BMI is a good measure of much, but it’s a useful reference in this case.)
When newborns are small for gestational age, they typically have a period of rapid catch-up growth, and are more likely to become “ob*se” later in life.
I remember a few years ago when a client who was in her early 70s told me that when she was pregnant, her doctor instructed her to gain as little weight as possible — and she was in a “normal” weight body!
Unfortunately, plenty of people across the weight spectrum still restrict calories, whether they’re struggling with a restrictive eating disorder, they’re trying to lose those “last few pounds,” or they’re trying to force their genetically predisposed fat body into the mold of the thin ideal.
Also unfortunately, pregnant women in higher-weight bodies are still told gain less weight than women in “normal” weight or lower weight bodies, as fetuses can live off their mother’s body fat.
Both mother and baby need adequate calories and nutrients from food, and when calorie intake goes down, nutrition usually goes down, too, especially if you have to also devote time and energy to things like a job (or two, or three), other children, laundry, possibly elder care, and can’t micromanage the nutritional content of each meal. In other words, most people.
The big picture
To be fair, gaining “too much” weight during pregnancy can also cause issues, but the hyperfocus on avoiding “too much” gain without accompanying support to make sure pregnant people meet their nutrient needs is deeply concerning.
And as I think I’ve explained, this isn’t just about the future weight of the unborn child, it’s about their future health. Weight is what it is, and while many health issues are “associated” with higher weight, thin people develop diabetes, heart disease, anxiety and depression, too.
In spite of all this, some physicians, who I sort of want to kick in the shins, believe that the weight gain targets are too high, especially for overweight and obese women.
Every pregnant person’s body is different, and increasing food intake during pregnancy isn’t just about amount of calories, it’s about amount of critical nutrients such as folic acid, iron and choline. And, as I wrote about in The Seattle Times this week, it appears that many more pregnant individuals are falling short in this area.
Because many pregnant people don’t have access to stellar pre-natal care, I really worry that a standard recommendation to not gain “too much” weight may not account for differences in nutritional status.
Again, the fewer calories someone takes in, the harder it is to hit important nutritional marks, because you have less food to do it with. That’s true whether someone is experiencing famine, is doing a “good old-fashioned” calorie-restricting diet, or is taking a weight loss medication that is reducing appetite to the point where they are eating very little.
Just some food for thought.
Carrie Dennett, MPH, RDN, is a Pacific Northwest-based registered dietitian nutritionist, journalist, intuitive eating counselor, author, and speaker. Her superpowers include busting nutrition myths and empowering women and men to feel better in their bodies and make food choices that support pleasure, nutrition and health. This post is for informational purposes only and does not constitute individualized nutrition or medical advice.
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