Monday, March 2, 2015

Weight Bias in Maternity Care: Weight Harassment and Over-Testing


Here is an email I received some time ago, detailing one plus-size woman's experiences with weight bias and harassment during pregnancy. I have redacted her name and location to protect her identity.

Her story perfectly illustrates several common forms of weight bias and obesity stigma that negatively impacts her medical care.

Is it any wonder that many people of size avoid seeing care providers when this is the treatment they get?

The Story
My name is xxxx, I live in xxxx with my [four children] and husband and I am a plus-size mama expecting my 5th child...I am 5' 5" and weigh around 200 lbs. (sometimes more, sometimes less).  I am a very active person, work out every day, keep a vegetarian diet and have never had any health problems whatsoever. 
When I had my first child I weighed 180. For my first 4 children I had an OB who is around 5 feet tall and a size zero who lectured me CONSTANTLY about the perils of being an "obese mom" and hounded me about every single ounce I gained.  
With all of my children I had terrible hyperemesis for the first 18-25 weeks, sometimes longer (and have had it again this time around, too) and that OB would tell me what a "Godsend" the hyperemesis was because it caused me to LOSE weight during that portion of my pregnancies (because of the hyperemesis I have only ever gained 20 pounds or less during any pregnancy). Her harassment got so bad I would wake up on the morning of appointments crying because I knew I had to go for a weigh-in. 
She even told me it would be better if I DIDN'T breastfeed any of my babies so I could immediately put myself on a 1000-calorie a day diet and take caffeine pills post partum to start losing weight rapidly before my obesity "killed" me. Thank goodness I didn't listen to this and breastfed all my girls till they were over 2. I believe I put up with all this treatment from my OB for years because I thought as a plus-size mom I "deserved" all the hostile behavior. 
When I found out I was pregnant with this baby (due in June) I decided enough was enough and switched my care to a highly recommended midwife practice so I would never have to see my previous OB ever again. At my first midwife check-up I was sick as a dog and weighed in at 207 lbs. My blood pressure was completely normal (as it always has been). I liked the midwife and I thought all was going well, had a positive prenatal exam, put on my clothes and was about to go to reception to make my next appointment when the midwife suddenly came back in and said she "forgot" to talk about an "issue."  
I sat back down and she proceeded to tell me my BMI labels me as obese (like I didn't know!) and as a result she wanted me to sign on for gestational diabetes testing EVERY FOUR WEEKS (I have NEVER tested positive for this, by the way!), wanted me to come in for "blood pressure checks" at the office every week even when I didn't have an appointment because she was sure I would develop high blood pressure due to my size, and then told me if I gained more than 5-10 lbs while pregnant I was seriously endangering my life!!  
I practically burst into tears! I've still been getting my care from her because I haven't been able to get in to see any of the other midwives in the practice with my schedule and don't have time to find another practice. I haven't been doing the monthly gestational diabetes testing (I tested negative on my first check and haven't been back) because I don't have time for it AND haven't been in for any of the aggressive extra blood pressure checks (I haven't had any high readings for appointments).  
I don't understand the rationale in the medical community for harassing, scaring and berating plus-size expectant moms. I plan to try again to get to a weight that I (and only I) find more comfortable/ideal for me after I have this baby, when I think it is healthy to do so - but where is the wisdom in treating me like a "weight criminal" now?  
You were right in your article that midwives need to treat every expectant mom AS an expectant mom, not as a patient who needs aggressive treatment for weight who also happens to be pregnant. If I have NO signs of any health issues or pregnancy complications, and everything is fine with my baby, then how is it necessary to focus on my weight RIGHT NOW? It's frustrating and demoralizing, and that isn't how any woman should spend her pregnancy! 
The Lessons To Be Learned

It's important to share this mother's experience because many in the medical field are in denial about the amount and scope of weight bias in medicine.

There seems to be a particular lack of recognition of weight bias and its impact on maternity care of heavier women.

This woman's experience highlights several common forms of size bias in maternity care, and it's important that caregivers become more aware of not only of the more egregious harassment, but also of the subtle biases that negatively influence care of women of size.

1. First, the most obvious bias in this woman's experience is her care providers' constant harassment of her about prenatal weight gain.


It's one thing to encourage "obese" women to have good nutrition and to be careful about weight gain, it's another to harass women to the point that they cry just at the thought of having to go in and be weighed. That's just wrong on so many different levels.

Women should not have to be afraid to go to their care providers, and they should always be treated with dignity and respect, regardless of what the number on the scale is or whether that number has gone up or down. Duh.

2. Second, the scare tactics this doctor used over prenatal weight gain were WAY over the top.

Yes, current recommendations recommend that obese women gain 11-20 lbs., and there are some in the medical field who advocate even less gain. But as we have pointed out before, there are risks to very low gains (including more prematurity and small-for-gestational-age infants), and deliberately restricting to achieve very low gains may result in poor outcomes

I would also point out that this woman's BMI puts her in the "Class I Obesity" category (BMI between 30 and 35). Research is clear that very low gains in this group is particularly dangerous. Yet here is a woman of Class I Obesity being told to gain only 5-10 lbs.!

This is the risk of hyperbole around restricted weight gain in pregnant women of size; many care providers hear the media stories and are taking the advice to an extreme, especially for those in the overweight and Class I obesity categories.

3. Third, it's beyond irresponsible for this woman's first care provider to pressure her away from breastfeeding so that she could focus solely on weight loss postpartum.

For one thing, breastfeeding often helps women lose weight and fat more efficiently postpartum (though this experience varies from person to person). If the OB truly cared about weight loss, she would be encouraging this mother to breastfeed.

For another thing, research has clearly shown that long-term breastfeeding actually lessens the risk of developing diabetes and heart disease, not to mention certain types of cancer.

If she had succeeded in discouraging this mother from breastfeeding, this OB might have actually caused worse health outcomes. What kind of an idiot doctor does not know this research?

4. Weight bias can take more subtle forms, too, like over-testing for complications.

Because obese women are at increased risk for blood sugar or blood pressure issues in pregnancy, many care providers assume that an obese woman will (or almost surely will) develop gestational diabetes or pre-eclampsia. As a result, may implement extreme over-testing. (I'm hearing about this more and more these days.)

This mother was encouraged to undergo monthly testing for gestational diabetes (rather than one test early and one test around 26 weeks or so) and WEEKLY blood pressure checks. This is an outrageous amount of over-testing and completely unnecessary, especially given the fact that the mother had never had blood sugar or blood pressure issues in her four previous pregnancies.

Most care providers do not require such frequent testing of blood sugar or blood pressure for their high-BMI clients ─ but some do, showing an inflated sense of risk about plus-sized pregnancies.

There is NO study ANYWHERE which shows that 100% of obese women develop these complications. In fact, although the prevalence of these conditions is increased in high BMI women, the research shows that many obese women do NOT develop them.

Over-testing is costly, invasive, and also has potential for harm. While it is important to be aware that high-BMI women are at increased risk for certain complications, it is also important to keep that risk in perspective and not over-react. Excessive testing is a major form of over-reaction to exaggerated perceived risk, and seems to be becoming more common.

5. Finally, the use of The Death Card is particularly offensive. 

"The Death Card" is frequently used with fat patients and is often used for the purpose of medical bullying, shaming, or scaring that person into compliance with the caregiver's directions. Counseling about risk is one thing, but The Death Card has no place in good medical care.

This mother was told that she would "seriously endanger" her life if she gained more than 5-10 lbs. in her pregnancy. This is complete nonsense. There is NO research to suggest that if an obese woman gains more than 10 lbs. that she is endangering her life.

Furthermore, the anecdotal experience of thousands of obese women (who typically gain somewhere between 10 and 25 lbs. in pregnancy and somehow manage not to die) contradicts this scare tactic. So does the experience of this mother herself, who had gained around 20 lbs. with previous pregnancies and was just fine.

Summary

The over-the-top mistreatment of obese women has gone too far. While there are care providers who provide gentle, respectful care to women of size (thank you!), I hear stories of weight bias like this far too often.

This kind of treatment is the result of researchers' (and media people's) exaggeration around risk in the pregnancies of women of size. It is also the result of the shaming, dehumanizing medical school "education" many care providers received on the topic of obesity.

It is time for medical schools and researchers to lay off the rhetoric and the shaming, and to focus on how to provide real health care for people of all sizes.

Women of size should not be treated like "weight criminals" when they are pregnant...or indeed, at any time EVER. Gentle, respectful care should be the norm for ALL people, whatever their size. 

*What would you like to tell this mom's care providers?

Saturday, February 14, 2015

Diet and Exercise No Cure for Obesity



A recent article (written by weight-loss doctors, no less) finally pointed out what we have been saying for so long ─ that very few fat people actually lose weight and keep it off successfully long-term, that it's NOT just about eating less and moving more, and that the body actually has biological mechanisms that work very strongly against weight loss efforts. Here's a quote:
A group of respected physicians has stepped forward to challenge the common assertion that obesity can be easily fixed by diet and exercise. 
For most of the nation’s 79 million adults and 13 million kids who are obese, the “eat less, move more” treatment, as currently practiced, is a prescription for failure, these doctors say.
In a commentary published Thursday in the journal Lancet Diabetes and Endocrinology, four weight-loss specialists set out to correct what they view as the widespread misimpression that people who have become and stayed obese for more than a couple of years can, by diet and exercise alone, return to a normal, healthy weight and stay that way. 
...The depressing fact, said Ochner in an interview, is that “the average adult with sustained obesity has less than a 1 percent chance of reattaining and maintaining a healthy body weight without surgery...What really bothers me working around and with clinicians, is that some of them — a disturbing percentage — still believe it’s all about personal choice: that if the patient just tries hard enough, and if we can just figure out how to get them a little more motivated, then we’d be successful. And that’s just not right.”
Of course, this commentary was not perfect, naturally. The authors seem to assume that all fat people are average-sized people who only get fat over time, ignoring the many people who have higher-BMIs consistently throughout their whole lives (suggesting genetic and metabolic mechanisms). And because of this, they still called on doctors to intervene more stringently among "overweight" patients in hopes of preventing them from becoming "obese," and to aggressively use weight-loss surgery, medications, and devices with obese people to get that weight down. (Sounds like WLS surgeons trying to increase business, frankly. And it conveniently ignores the fact that it's weight loss interventions and pressure on "overweight" and Class I "obese" patients that often lead to more obesity rather than less.)

But it was refreshing to hear doctors admit what we have known for so long, that it's not just about eating less and exercising more, that success with permanent weight loss is extremely unlikely, and that the bias of what doctors want to believe about fatness is increasing stigma and inhibiting actual good care of these people.

Tuesday, February 10, 2015

Adventures in Gardening: Hügelkultur Experiments

Periodically, I write about gardening on this blog. I'm sure some readers scratch their heads and wonder why, given that I generally focus on issues pertinent to weight or on pregnancy/birth/breastfeeding, but I view gardening as part of the mission of this blog too.

I write about gardening for several reasons. First and most importantly, I write about gardening as part of my Health At Every Size focus. I think it's obvious that as a society, we would be better off if we ate fewer processed foods and more whole foods, and gardening is an important part of the "slow food" movement. It promotes better nutrition and gives us exercise, all in one convenient package. Not that we all have to be perfect or obsessive, but striving for more whole foods is just common sense.

Second, I write about gardening as part of my Parenting focus. Kids will eat more vegetables and fruit if they help grow it themselves, and it's good for kids to appreciate the kind of work it takes to provide the food we eat. Far too many kids have no concept of how food reaches their table. Gardening also helps kids connect with nature, gets them outside, gives them exercise, and helps them learn to care responsibly for living things. I think every child should learn to garden in one degree or another.

Finally, I write about gardening as part of my Emergency Preparedness message. It's important as parents to have a stock of food on hand in case of a natural disaster or other emergency. Too many people are completely dependent on grocery stores for all their food, and most have very little stored food in reserve for emergencies. Gardening helps you have a renewable source of healthy food for your family. Gardening also lends itself to preserving, which helps you keep a stock of preserved food around. It's important that we keep gardening and preserving skills alive for our children, and it's also important to have a food reserve for our families in case of an emergency.

Gardening is a win-win all around on so many levels. Even though it might not seem like a logical topic for this blog on the face of it, it really does fit my blog mission too.

Today I wanted to share about a gardening experiment I've been toying around with this year. It's called Hügelkultur gardening.

Raised Beds on Steroids

Since a big car accident a few years ago significantly damaged my knees, I mostly garden in raised beds now. Saves my knees a lot of grief and my back likes it too. I'm a real fan of raised beds.

But raised beds have challenges too. They are more watering-intensive; they dry out sooner and need to be watered more often. Being the lazy, less-than-attentive gardener that I am, I'm not always good about watering regularly, which can be stressful on the vegetables.

Also, the soil in raised beds can get "tired out" and depleted of nutrients if you don't refresh them regularly. I prefer to garden organically, so I've been experimenting to see how I can best "feed" the soil in my gardens without having to resort to artificial fertilizers or additives.

It was in response to these challenges that I began to learn about a new/old technique called Hügelkultur Gardening (pronounced HOO-gull-cul-ture). 

Hügelkultur Gardening Basics

First layer of hugelkultur bed - pieces of wood in various
sizes. Image by Jon Roberts, from Wikimedia
Although Hügelkultur gardening has been practiced in several different cultures, the name is German and the idea was popularized by permaculturist Sepp Holzer.

Basically, it means "Mound Culture" or mound gardening. You pile a bunch of wood in various stages of decomposition at the bottom of the pile, water it in well so the wood soaks up the water, then add other layers of soil, kitchen waste, leaves, straw, compost, manure, bark chips, etc. until you have a mound. Then you plant in that mound.

Sometime the mound is small, sometimes it's large, but you basically are planting in a compost pile that's in process. Using different sizes of wood means that it processes slowly and that the nitrogen from the kitchen waste etc. does not overwhelm the carbon content, which is a common problem in many compost piles.

The benefits of hügelkultur are:
  • it improves soil fertility (through decomposing organic matter)
  • it aerates the soil and improves its structure (the soil around the logs naturally creates air pockets, which helps keep the soil from compacting to much, thereby improving its structure)
  • it improves water retention (water is released slowly over time from the water-soaked logs, necessitating less watering in the drier months after the first year or two)
  • it warms the soil (making it easier to plant earlier and longer in the growing season)
  • it promotes earthworms and other beneficial animals/fungi in the garden (they are attracted to the decomposing organic matter and help break it down)
Permaculturists like hügelkultur because it recreates replenishment of soil in the garden in the same way that it happens in nature:
Hügelkultur replicates the natural process of decomposition that occurs on forest floors. Trees that fall in a forest often become nurse logs decaying and providing ecological facilitation to seedlings. As the wood decays, its porosity increases allowing it to store water "like a sponge". The water is slowly released back into the environment, benefiting nearby plants.
Image from richsoil.com 
Personally, it's the watering benefits I'm most interested in. While my area of the country gets lots of moisture in the winter, we get very little during the summer, so we have to do a lot of watering in the summer. My new hügel bed is on the side of my house that doesn't have easy watering access, and it's far away from the raised garden beds that get my main (if inconsistent) watering attention. I wanted more gardening space but less upkeep, so I'm hoping the new hügel bed will help by giving me a new garden space that I don't have to spend so much time watering.

There are lots of different ways to do hügel beds. Although it is helpful to read up on ways to optimize the process, it's basically just planting into soil mounded over buried wood. Some online accounts make it seem complicated, but if you keep in mind the basics, the process is pretty forgiving.

Some people like to build their hügel beds in a trench. You dig a long hole, pile up woody debris in it, then fill in the gaps with kitchen waste, compost, straw, etc. until you have a good mound. The digging part can be a lot of work, so some gardeners don't bother with the trench; they just pile the woody debris directly on the ground and then fill in the gaps. Personally, I used a trench because I think it gives more stability to the mound and because putting the wood directly in the earth accelerates its decomposition, brings more worms, and enhances water retention in the dry months.

Some writers suggest building your hügelkultur beds to run in a line north to south. This is to maximize sun exposure (otherwise, the mound nature of the bed means one side of an east-west bed will get too much shade). Some surround the base of the hügel mound with rocks, logs, or other materials for stability and neatness; others do not. Rocks along the edges may help warm the soil better, but otherwise it's a personal choice.

It's important to use different sizes and ages of wood in the bed if possible. You want some to be old and partially decomposing already, some to be new, some to be thick pieces of wood, and some to be small thin twigs and branches. If you start with all-new and thick wood, your hügel bed may not do as well for the first couple of years, since it needs time to absorb water and start the decomposition process. For maximum benefit, use wood of various sizes and states of decomposition, and start your hügel bed in the fall so that the wood can absorb the winter moisture before planting in the spring.

If you don't have enough woody material of your own, look around. Tree-trimming companies, power companies, and government agencies often have some you can get, or you can collect fallen wood from a friend's back yard, etc. Just make sure it's untreated wood. No plywood or treated lumber should be used.

Another suggestion I've read is to put some of the wood in vertically instead of horizontally, especially if using less water is one of your priorities. Supposedly the wood wicks moisture more efficiently if it's vertical instead of horizontal. I can't speak to this but it seems plausible to me.

Some authors also suggest adding alfalfa pellets when building the bed in order to add more quickly-available nitrogen to balance the carbon dominance of the bed in the first year or two. If you don't have much manure available, this might help. After that, the wood should start breaking down and create its own balance of carbon and nitrogen.

(As an alternative, some people suggest pouring diluted urine or peeing directly onto the logs, but surprisingly, my teen-aged boys declined to do this. I thought they'd love the chance to mark their territory but they were absolutely appalled by the idea.)

Alternate layers of greens and browns in your pile, like in "lasagna gardening" (sheet mulching). Use kitchen waste, garden waste, bark chips, manure, straw, grass clippings, whatever you have on hand. Top it all off with a thick layer of compost and then straw or other mulch to help keep the soil in place and hold in moisture. When you plant, simply move aside some of this top layer and plant the start (or seed) directly into the pile. When you see the seedling is high enough, put the mulch back around it. The first year or two you will have to water seedlings more often, but after that you should have to water much less often.

The more organic material you add (especially nitrogen material) on top of the wood, the sooner your bed will produce results. If you have mostly woody material with minimal soil, it's going to take a couple of years to start breaking down and you won't get much results until then. But if you start with well-watered wood in all stages of decomposition, then add lots of nitrogen-rich material and soil layered with smaller carbon materials (like straw or bark chips), you should be able to plant in the first year and get reasonable returns.

Each year, the organic materials will break down more and more, so you'll need to occasionally add more compost, leaves, manure and bark chips to the hügel beds over the years. Just fill in the holes periodically. The best growing results are typically several years into the process.

But really, although these are suggestions to make hügelkultur more efficient, there's not a lot of strict rules to follow. It's a very forgiving approach, which is why I like it. You can make it what you want and adapt it for your own needs.

My Hügelkultur Beds

Hügelbed, minus top layer of soil.
(This is not my hügelbed, but mine looks
a lot like this, not very mounded yet.)
Image from Wikimedia.
Personally, I started my hügel bed in a small trench and filled it with fallen tree limbs, some firewood, and some old branches and logs from our school grounds. (If I were to do another hügel bed, I think I'd add in even more wood, as I don't think we have enough in there to truly go without extra watering.)

My hügel bed is more of a mini-hügel than a true hügel. The classic hügel is a very high mound with very steep sides. I do not have enough soil and compost right now to make a mound that high, so I'm doing what works at my property...a mini-hügel. It won't last as long, but it should still last several years. That's good enough for a first experiment.

I let the wood get good and soaked in the fall rains, then we began covering it up with layers of kitchen scraps, manure, straw, wood chips, grass clippings, half-cooked compost, the original soil from the trench diggings, garden leftovers, and dead leaves. At this point, it's not very mounded yet, so we need to add more compost, straw and other materials this spring to continue to build it up.

The top of the pile has last year's Halloween pumpkins on it; I'm hoping they seed and start new pumpkins in the pile for this year. Pumpkins are supposed to love hügel beds. My hügel bed is in the former rabbit pen, so it should have lots of good rabbit poo to make the pumpkins happy, and the pumpkins will have lots of room to spread out and grow, which was a problem in my raised beds.

I plan to plant several berry bushes of different types in the hügel bed this year, mostly huckleberry, josta berries, and blueberries. These will form the backbone of the hügel garden, the "perma" in my permaculture. Their root structures will hopefully grow strong over time and give stability to the bed.

Some people also put stuff around the edges of the bed to give it stability, but since mine was built in a trench and isn't very mounded, I'm not too worried about this. I probably will put down some cardboard and bark chips around the edges of it to create a walking path and hopefully deter the grass from growing up the sides, though.

I will plant some nitrogen-fixing plants like peas and beans this year, which hopefully should help provide balance for the carbon in the wood pile underneath. This may be especially important in the first year of growing, since a hügel bed tends to be carbon-dominant at first. I didn't add any alfalfa pellets, but I may look into getting some to add to the beds (since my teens aren't cooperating with territory-marking plan).

In future years I will add more variety of plants, intercropped between the more permanent plants, but for now, I just want to get the basics in the bed and get it up and running. I'll probably have some annual greens there this year as an interim plan.

I like the hügelkultur idea so much that I'm trying to convert some of my raised beds on the other side of the house to a hügelkultur hybrid bed. I have my teenagers digging up the dirt in the raised beds, shunting it to the side, putting old soaked wood and branches in the bottom, and then mixing in kitchen waste, half-finished compost, rock/mineral dust, straw, bark chips, and manure into the rest of the soil. They won't be true hügelkultur beds because they won't have nearly as much wood, but will hopefully give my raised beds a good shot of soil replenishment ─ and maybe lessen watering requirements if I'm lucky.

I wrote previously about my experiment with trench composting, i.e. composting my kitchen waste directly into holes in the raised gardens. Overall, that has been great (far better than messing with a compost pile!), but I did notice that some of my raised beds tended to have too much nitrogen this year. As a result, some of my tomatoes had tons of green growth but not as much fruit in some places.

So the hügelkultur hybridizing of my raised beds will hopefully also help bring more carbon to balance the nitrogen created by the trench composting, which I love and want to continue. Hopefully, a better balance between "browns" and "greens" in the garden will create maximum produce production.

Although it's still early in the process, I'm pretty optimistic about the Hügelkultur beds I'm creating. Since it simply re-creates the process as it happens in nature, I think it has a great chance of succeeding and will greatly add to the productivity of my garden. Better yet, I'm hoping it will lessen the amount of watering, fertilizing, and fussing I need to do, which would be great because I'm a very lackadaisical gardener. I enjoy it when I get around to it, but I have too many other time demands and interests to obsess about it too much.

If you are interested in Hügelkultur for your own gardens, check out some of the links below. Happy gardening!


Resources

Wednesday, February 4, 2015

Another Reason Not to Schedule a Pre-Labor Cesarean

Here is an interesting recent study showing that women who had a scheduled pre-labor cesarean had an increased risk for Placenta Previa (low-lying placenta, near or over the mouth of the cervix) in a subsequent pregnancy.

Although rare, previas present significant risks to both mothers and babies. These include severe hemorrhage and hysterectomy for the mother, as well as prematurity, breathing issues, and the need for Neonatal Intensive Care Units (NICU) for the baby. That's why it's important to reduce the risk for previas whenever possible.

The important finding in this large, multiple-hospital study was that women had a higher risk for previa if they had a pre-labor cesarean than if they had a vaginal birth or a cesarean that occurred after the start of labor. 

Although the risk for previa was increased in women who had a cesarean that occurred during labor, this increase did not rise to statistical significance.

But the risk for previa after a pre-labor cesarean was more than doubled. That's a troubling finding, and suggests that we should not take scheduled cesareans lightly.

This may be particularly important finding for very high-BMI women, who are increasingly scheduled for pre-labor "elective" cesareans without any chance at labor.

Of course, there are legit reasons to schedule a pre-labor cesarean. A small increase in the chance of previa in the next pregnancy does not justify avoiding a pre-labor cesarean if one is truly indicated.

However, if there is no true medical need for a pre-labor cesarean (and BMI does not qualify as a legit reason), then this is yet another reason not to just schedule an elective cesarean before labor.

More and more data indicates that labor is beneficial for both mom and baby...and in this case, possibly for future pregnancies as well.


Reference

Am J Obstet Gynecol. 2015 Jan 7. pii: S0002-9378(15)00005-8. doi: 10.1016/j.ajog.2015.01.004. [Epub ahead of print] Prior Prelabor or Intrapartum Cesarean Delivery and Risk of Placenta Previa. Downes KL1, Hinkle SN2, Sjaarda LA2, Albert PS3, Grantz KL4. PMID: 25576818
OBJECTIVE: To examine the association between previous cesarean delivery and subsequent placenta previa while distinguishing cesarean delivery prior to onset of labor from intrapartum cesarean delivery. STUDY DESIGN: Retrospective cohort study of electronic medical records from 20 Utah hospitals (2002-2010) with restriction to the first two singleton deliveries of women nulliparous at study entry (n=26,987). First pregnancy delivery mode was classified as 1) vaginal (reference); 2) cesarean delivery prior to labor onset (prelabor); or 3) cesarean delivery after labor onset (intrapartum). Risk of second delivery previa was estimated by prior delivery mode using logistic regression and adjusted for maternal age, insurance, smoking, co-morbidities, prior pregnancy loss, and history of previa. RESULTS: The majority of first deliveries were vaginal (82%, n=22,142), followed by intrapartum cesarean delivery (14.6%, n=3,931), or prelabor cesarean delivery (3.4%, n=914). Incidence of second delivery previa was 0.29% (n=78) and differed by prior delivery mode: vaginal, 0.24%; prelabor cesarean delivery, 0.98%; intrapartum cesarean delivery, 0.38% (P<0.001). Relative to vaginal delivery, prior prelabor cesarean delivery was associated with an increased risk of second delivery previa (adjusted odds ratio, 2.62 [95% confidence interval, 1.24-5.56]). There was no significant association between prior intrapartum cesarean delivery and previa [adjusted odds ratio, 1.22 (95% confidence interval, 0.68-2.19)]. CONCLUSION: Prior prelabor cesarean delivery was associated with a more than two-fold significantly increased risk of previa in the second delivery, while the approximately 20% increased risk of previa associated with prior intrapartum cesarean delivery was not significant. Although rare, the increased risk of placenta previa after prior prelabor cesarean delivery may be important when considering non-medically indicated prelabor cesarean delivery.

Thursday, January 29, 2015

The Many Benefits of Doula Care


The word "doula" comes from Greek and means "woman's servant." It referred to the women who traditionally provided support to mothers in labor.

The Doulas of North America organization (DONA) defines a modern-day doula in the following way:
A birth doula is a person trained and experienced in childbirth who provides continuous physical, emotional and informational support to the mother before, during and just after childbirth.
Some doulas only work during labor itself, but most doulas work with women before and just after the birth as well. They give emotional support and information as needed during pregnancy, provide support and encouragement during labor, and then give early post-partum and breastfeeding support.

Research has shown that having a doula during labor can help lower the risk for a cesarean, and may also help increase breastfeeding initiation rates. 

Professional labor support is probably even more important for women of size because women of size tend to be subjected to more labor interventions and restrictions and have higher cesarean rates and lower breastfeeding rates than women of average size. Doulas may be one powerful way of improving outcomes among high-BMI women. 

Here is the most recent research supporting the importance of more wide-spread access to doulas.


References

Am J Manag Care. 2014 Aug 1;20(8):e340-52. Potential benefits of increased access to doula support during childbirth. Kozhimannil KB1, Attanasio LB, Jou J, Joarnt LK, Johnson PJ, Gjerdingen DK. PMID: 25295797
...Retrospective analysis of a nationally representative survey of women who delivered a singleton baby in a US hospital in 2011- 2012 (N = 2400)...Six percent of women reported doula care during childbirth. Characteristics associated with desiring but not having doula support were black race (vs white; adjusted odds ratio [AOR] = 1.77; 95% CI,1.03-3.03), and publicly insured or uninsured (vs privately insured; AOR = 1.83, CI, 1.17-2.85; AOR = 2.01, CI, 1.07-3.77, respectively). Doula-supported women had lower odds of cesarean compared without doula support and those who desired but did not have doula support (AOR = 0.41, CI, 0.18-0.96; and AOR = 0.31, CI, 0.13-0.74). The odds of nonindicated cesarean were 80-90% lower among doula-supported women (AOR= 0.17, CI, 0.07-0.39; and AOR= 0.11, CI, 0.03-0.36)...Increasing awareness of doula care and access to support from a doula may facilitate decreases in nonindicated cesarean rates.
Am J Public Health. 2013 Apr;103(4):e113-21. doi: 10.2105/AJPH.2012.301201. Epub 2013 Feb 14. Doula care, birth outcomes, and costs among Medicaid beneficiaries. Kozhimannil KB1, Hardeman RR, Attanasio LB, Blauer-Peterson C, O'Brien M. PMID: 23409910
...We calculated descriptive statistics for Medicaid-funded births nationally (from the 2009 Nationwide Inpatient Sample; n = 279,008) and births supported by doula care (n = 1079) in Minneapolis, Minnesota, in 2010 to 2012; used multivariate regression to estimate impacts of doula care; and modeled potential cost savings associated with reductions in cesarean delivery for doula-supported births. RESULTS: The cesarean rate was 22.3% among doula-supported births and 31.5% among Medicaid beneficiaries nationally. The corresponding preterm birth rates were 6.1% and 7.3%, respectively. After control for clinical and sociodemographic factors, odds of cesarean delivery were 40.9% lower for doula-supported births (adjusted odds ratio = 0.59; P < .001). Potential cost savings to Medicaid programs associated with such cesarean rate reductions are substantial but depend on states' reimbursement rates, birth volume, and current cesarean rates. CONCLUSIONS: State Medicaid programs should consider offering coverage for birth doulas to realize potential cost savings associated with reduced cesarean rates.
J Midwifery Womens Health. 2013 Jul-Aug;58(4):378-82. doi: 10.1111/jmwh.12065. Epub 2013 Jul 9. Doula care supports near-universal breastfeeding initiation among diverse, low-income women. Kozhimannil KB1, Attanasio LB, Hardeman RR, O'Brien M. PMID: 23837663
...We compared breastfeeding initiation rates (means and 95% confidence intervals) for 1069 women who received doula care from Everyday Miracles, a Minnesota-based organization that employs a diverse group of certified doulas, to a state-based sample of women with Medicaid coverage who gave birth in 2009 or 2010 and participated in the Minnesota Pregnancy Risk Assessment Monitoring System survey (weighted n = 51,721). RESULTS: Women who had doula-supported births had near-universal breastfeeding initiation (97.9%), compared with 80.8% of the general Medicaid population. Among African American women, 92.7% of those with doula support initiated breastfeeding, compared with 70.3% of the general Medicaid population. DISCUSSION: These results suggest that access to culturally appropriate doula care may facilitate higher rates of breastfeeding initiation. When supported in their nonmedical needs by birth doulas, the diverse, low-income patients of midwives and other maternity care providers may have a greater likelihood of initiating breastfeeding and experiencing the maternal and infant health benefits associated with breastfeeding.
Cochrane Database Syst Rev. 2013 Jul 15;7:CD003766. [Epub ahead of print] Continuous support for women during childbirth. Hodnett ED1, Gates S, Hofmeyr GJ, Sakala C. PMID: 23857334
BACKGROUND: Historically, women have been attended and supported by other women during labour. However, in hospitals worldwide,continuous support during labour has become the exception rather than the routine...Twenty-two trials involving 15,288 women met inclusion criteria and provided usable outcome data...Women allocated to continuous support were more likely to have a spontaneous vaginal birth (RR 1.08, 95% confidence interval (CI) 1.04 to 1.12) and less likely to have intrapartum analgesia (RR 0.90, 95% CI 0.84 to 0.96) or to report dissatisfaction (RR 0.69, 95% CI 0.59 to 0.79). In addition, their labours were shorter (MD -0.58 hours, 95% CI -0.85 to -0.31), they were less likely to have a caesarean (RR 0.78, 95% CI 0.67 to 0.91) or instrumental vaginal birth (fixed-effect, RR 0.90, 95% CI 0.85 to 0.96), regional analgesia (RR 0.93, 95% CI 0.88 to 0.99), or a baby with a low five-minute Apgar score (fixed-effect, RR 0.69, 95% CI 0.50 to 0.95)...AUTHORS' CONCLUSIONS: Continuous support during labour has clinically meaningful benefits for women and infants and no known harm. All women should have support throughout labour and birth.


Saturday, January 10, 2015

Test Those Smoke Detectors Frequently

Last week, my husband almost burned down our house while cooking dinner.

The good news is that he didn't actually burn down the house. It was all smoke, albeit pretty thick smoke; I caught it before it turned into flames.

The bad news is that it probably ruined a beloved pan I got from my mother, and the house still smells a bit like scorched metal. Hopefully that will disappear soon.

The unsettling news is that this was a good check of our smoke detectors ─ and we found that they totally FAILED the test. Ulp! So now we are working on fixing that issue.

My husband is a great guy with many many sterling qualities, but he has a bad habit of putting something on the stove and then leaving the room, forgetting about the item on the stove. I've rescued many scorched things over the years, and have had to throw out more than a few. (I have to be fair ─ I've been known to put something on the stove and forget about it once in a while. You really shouldn't leave the room if you have anything on the stove.)

Well, that's what he did last week. He put a pot of beans on the stove to boil, then took the kids out, forgetting the pan on the stove. I stayed behind to work on the computer but he didn't tell me that he was cooking anything.

Thank goodness I stayed home! After quite a while I smelled the burning pot and went to investigate. Sure enough, there was the pot of beans on the stove, scorching like crazy. Luckily, I got to them before any flames actually began, but it was obviously only a matter of time before that had happened too. If I hadn't been at home, it might well have happened.

The most alarming part was that the house was filled with smoke, yet not a single smoke detector was going off. 

Sometimes there's not enough smoke to really set off a detector, even though it looks pretty smoky. But that's not what happened here. Nope, there was more than enough smoke to warrant a smoke detector going off this time, but not one did. Uh-oh.

We usually check our smoke detectors during daylight savings time changes in fall and spring. But sometimes I ask him to do that and he says he's done it, yet it turns out he didn't really do it. (Does your spouse ever do that?) That's what happened this year.

When we checked, it turns out that there wasn't a single smoke detector on the main floor of the house that was working properly. Doh!

And not only that, you're supposed to check the batteries on smoke detectors every six months (at the time changes) and change the batteries every year ─ PLUS you are supposed to test the smoke detectors every month. We were only testing them every six months (and apparently not always even then). Oops.

Thank goodness we hadn't had a fire. We would have been out of luck.

As a parent, I'm all about preparing for emergencies, as long-time readers of the blog know. Mostly I prepare for scenarios involving weather issues (snowstorms, windstorms), power outages, or earthquakes (we live in a major earthquake zone). Although I joke about the Zombie Apocalypse, I don't really get too concerned about the scenarios that many preppers worry about, honestly. I can't say I'm not concerned, but honestly I don't think most are very likely.

But natural disasters? Those happen regularly. It makes much more sense to focus your prepping on the kinds of scenarios that statistics show every area encounters periodically, rather than focus obsessively on a rare something that might or might not happen someday.

Yet you should always focus on fire safety first and foremost, because FIRE is the life-threatening emergency scenario you are most likely to face in your life. 

The Red Cross notes that, on average, 7 people die every day from a home fire. Fires kill more Americans each year than all other natural disasters combined.

But having a working smoke detector cuts the risk of dying in a home fire in half.

The Red Cross estimates that nearly 900 lives a year could be saved if only every home had working smoke detectors.

So go now, go check your smoke detectors. While you're at it, add some Carbon Monoxide detectors too. 

And don't forget to push the button regularly and test to see if these detectors actually work.


Resources

For more information:

Sunday, January 4, 2015

Recent Studies on Inositol for PCOS

Here are the abstracts of some new studies on the use of inositol (d-chiro-inositol or myo-inositol) in women with Polycystic Ovarian Syndrome (PCOS).

Inositol is a naturally-occurring substance in our foods that helps us process insulin properly. Normally, our bodies convert substances in plants and animals into several different forms of inositol. Two of these inositols are used in insulin-signaling pathways. However, some research suggests that women with PCOS do not use inositol properly, leading to insulin-signaling problems. 

These defects in insulin signaling means that the body has to over-produce insulin to compensate. The insulin that is produced does not get used properly, causing excess amounts to stay in the body.

This in turns stimulates the production of androgens ("male" hormones), leading to an imbalance in hormones in the body and many of the distressing symptoms of PCOS (including hirsutism, alopecia, acne, and difficulty ovulating).

And because the body struggles to use its insulin properly, this can lead to increased blood sugar issues over time. This is why many women with PCOS become diabetic at some point in their lives.

Now, however, emerging research suggests that supplementing the body with these inositols may help insulin signaling, thus lowering insulin resistance and improving blood sugar. It may even help lessen PCOS symptoms.

We've discussed inositols before in detail, here, which can be read for a good start on the subject. But right now let's take a look at some of the latest thinking on inositols, as well as on studies that have been released since that original post or were not cited in it.

How Inositols Work in Insulin Signaling

First, a little background for those new to the topic.

Inositols act as "second messengers" in insulin signaling. They play a very important role in how we use insulin.

Insulin produced by the body binds to insulin receptors on the cell walls. From there, the receptor generates second messengers (inositolphosphoglycans, or IPGs) to relay and amplify the signal to help the body use the insulin effectively.

But women with PCOS seem to have a defect in their second messenger pathway. This could explain why they have such strong insulin resistance. One PCOS resource simplifies it this way:
When we eat foods (mostly carbohydrates), they get converted into glucose in our blood stream. We need the glucose to enter our cells to be used for energy. When blood glucose levels rise, a signal (imagine a doorbell is rung) is sent from the cell door to the nucleus telling it to open up. However, with PCOS, the doorbell on the cell door may be defective. This means that it takes longer for the cells to open its doors to glucose resulting in higher amounts of insulin needing to be secreted. Secondary messengers acts to repair the doorbell so that the cell doors open in response to glucose, resulting in less insulin needing to be secreted. 
Improving this second messenger pathway could also become a radical new way of treating PCOS. As one review noted:
The discovery that the impairment in the insulin signalling could be due to a defect in the inositolphosphoglycans (IPGs) second messenger pathway opened a new horizon in the clinical management of PCOS. IPGs are known to have a role in activating enzymes that control glucose metabolism. In PCOS women, a defect in tissue availability or altered metabolism of inositol or IPGs mediators may contribute to insulin resistance
So the problem in PCOS may simply be errors in the second messenger insulin signaling pathway, and treating women with some form of inositol may help bridge the errors in this pathway.

The question is, which is the most effective form of inositol and should the type/dosage used depend on its purpose?

Which Form of Inositol Works Best?

Two forms of inositol get the most attention in PCOS research:
  • myo-inositol (MI or MYO)
  • d-chiro-inositol (DCI)
Both are forms of inositol, just slightly different stereoisomers. Both play important roles in insulin signaling; their roles are different but complementary.

MI is usually seen as a precursor to DCI; evidence suggests that the body converts myo-inositol to d-chiro inositol. Another inositol stereoisomer, d-pinitol, is also thought to convert into DCI in the body, but MI is thought to be the more important source.

However, many women with PCOS seem to have difficulty with the conversion from MI to DCI, suggesting that PCOS may be caused (or at least influenced) by errors in inositol metabolism. 

So, the theory goes, if we supplement the body directly with inositol, that might help help replace what's missing or make it work more efficiently.

As a result, people have been experimenting with inositol supplements, either myo-inositol or d-chiro-inositol. And the results of these experiments have been promising so far, both in research and anecdotally.

One of the most important questions that has yet to be answered is whether myo-inositol or d-chiro inositol (or some combination of the two) is the best treatment for women with PCOS and what the best dosage/treatment regimen would be.

MI is the form of inositol that is cheapest and easiest to use. It can be bought in capsules over the counter in many health food stores or in bulk powder over the internet. The thought is that if you take enough of it, then the body will convert more of it into DCI and improve insulin signaling, thus decreasing PCOS symptoms and health issues.

On the other hand, DCI is the form that seems to work best on improving hyperandrogenism and possibly insulin resistance. If some women have difficulties converting MI to DCI, why not skip to the chase and supplement directly with DCI?

Early studies on DCI had excellent results and so DCI was the focus of most research at first. However, subsequent studies were not able to replicate these results, so the drug companies largely abandoned DCI as a line of inquiry in 2002. DCI seemed discredited at that point.

What the research since then has suggested is that the initial follow-up studies didn't replicate the studies exactly ─ they increased the dosage in hopes of even better effect. But it seems that they increased the DCI dosage too much ─ apparently, there is a point of diminishing returns with DCI, beyond which it ceases to be helpful, particularly with fertility concerns. So the reason the follow-up studies didn't validate the original studies was because they used a too-high dosage, not because DCI was not potentially useful.

After the supposed "discrediting" of DCI, research on inositols was minimal and mostly focused on MI. Once researchers realized that a too-high DCI dosage was counter-productive and that MI also had benefits, research began to increase on both inositols.

Since myo-inositol is much cheaper and easier to produce, research still often focuses on MI. But some providers still feel that a moderate dose of DCI is a better choice. Still others feel that a combination of MI and DCI should work better, since both work on insulin signaling in different ways.

So what we do know is that there is no clear consensus on inositols yet but that data is emerging and it's important to keep up on the latest research.

Current research seems to suggest that MI is the inositol of choice for PCOS women with fertility issues (it especially seems to improve egg quality) and that MI works better than DCI for fertility treatment.

On the other hand, DCI may be better for those PCOS women with major hyperandrogenism issues and for whom fertility is not a major concern.

The jury is still out on which form is better for significant blood sugar/insulin resistance issues; there is research to support either MI and DCI (or both) for this purpose.

The very latest trend seems to be having women with PCOS take both MI and DCI in a 40:1 ratio (MI to DCI). This usually translates to MI (2-4 grams) and DCI (50-100 mg), but exact dosages will vary from person to person.

Recent research suggests this combination seems to be more effective than either MI or DCI alone. This is logical if they do indeed work on insulin signaling in different ways.

But it may be that the best treatment regimen may differ from woman to woman because the degree of impaired conversion may differ from person to person.

Remember, PCOS tends to have a spectrum of severity. Some have only mild symptoms while others have very severe symptoms. This may reflect a spectrum of efficiency in conversion of MI to DCI. As one resource speculates:
Considering the spectrum of human genetic diversity (take height for example), why should this trait be black/white, yes/no, or on/off? With a little imagination, we can see this impaired conversion of myo-inositol to D-chiro-inositol as a spectrum. Some women make the conversion efficiently, and they have no symptoms of PCOS. Others may make the conversion with some degree of efficiency, but not quite enough to have an optimal MYO/DCI ratio. Their symptoms may be mild. At the other end of the spectrum some people would be completely unable to make this conversion, and they would consequently present with the most severe symptoms. And, as part of the human tapestry, there would be everything in between as well.

Which brings us to the question of which inositol is right for me? Along this spectrum, people who are completely unable to convert myo-inositol to D-chiro-inositol are only going to benefit from supplementation with D-chiro-inositol. Other people who make the conversion, but with less than optimal efficiency, may benefit from large doses of myo-inositol. And, folks in between, might see the best results from a blend of the two.
In other words, some women with PCOS seem to convert MI to DCI pretty well, in which case they probably don't need to take supplemental DCI, just MI. However, others probably do not convert MI to DCI very well and may benefit more from just DCI. Still others may do best with a combination of both.

How are we to know which treatment regimen to try? As always, we need bigger and more qualitative studies to guide our choices.

But in the end, it may also be that each woman (in concert with her care provider) has to experiment and find the right regimen and dosage for her unique needs. 

Summary

More and more research is being done on the use of the inositols for PCOS, and most of this research so far is very encouraging. Some researchers are even suggesting that:
...the combined administration of MI and DCI in physiological plasma ratio (40:1) should be considered as the first line approach in PCOS overweight patients.
As we have seen, the most important benefit of inositols may be in improving insulin signaling, thus reducing insulin resistance and lessening PCOS symptoms. If insulin resistance is the major issue with PCOS and research continues to be promising, then inositols may become the key element to treating it. They may be especially useful for those who cannot tolerate metformin.

But there may be other benefits beyond improving the insulin-signaling pathway. For example, inositols are thought to also help the liver to metabolize fat, which may be helpful to those PCOS women with NAFLD (Non-Alcoholic Fatty Liver Disease).

In addition, inositols act as "signal transduction systems" in ways beyond insulin signaling pathways. They may also be related to the activation of serotonin receptors. Some research suggests that high doses of MI may reduce the risk of depression, which may be more common in people with PCOS.

There is only limited data on the use of inositols during pregnancy but some research suggests that use of myo-inositol may significantly lower the risk for the development of gestational diabetes in women with PCOS, in women with diabetic relatives, or in those who are at otherwise high risk for gestational diabetes.

However, keep in mind that most of the research trials on inositols have been very small, quite short-term, and are highly variable in methodological quality. Most are done in Italy and are not taken very seriously by many care providers in the U.S. or U.K. As a result, some researchers don't feel that any of the inositols have been adequately proven yet. And some care providers haven't even heard of inositols, so it can be difficult to find a provider supportive of trying this therapy.

Bottom line, we need more and better trials to know if long-term use of the inositols is safe and effective and to help care providers feel more comfortable with their use.

In particular, there are a few pressing safety questions that need to be addressed:

  • Some sources suggest that women who are on anti-depressants or medications for bipolar disorder may need to avoid inositols or use them only with great care since inositols may affect serotonin receptors
  • Some resources recommend that DCI not be used in conjunction with anti-androgen medications like spironolactone because the two together may be too effective against androgens and a certain amount of androgens are actually needed by the body
  • We need more data proving conclusively that inositols are safe in pregnancy
  • We need more data examining potential interactions with other drugs since many women with PCOS take other medications as well

In short, research on the use of inositols for PCOS is emerging and it behooves us to keep a close watch on emerging research to keep up with the latest developments.

The good news is that the results so far are promising. Below are the abstracts from some of the more important recent studies on inositol use.

*You can read more about the use of the inositols for treatment of PCOS herehere, here, and here. My original blog post about the use of inositols for PCOS can be found here


References

Overview

Eur Rev Med Pharmacol Sci. 2014 Jul;18(13):1896-903. Inositol: history of an effective therapy for Polycystic Ovary Syndrome. Bizzarri M1, Carlomagno G. PMID: 25010620 Free full text here.
Inositol is a physiological compound belonging to the sugar family. The two inositol stereoisomers, myo-inositol and D-chiro inositol are the two main stereoisomers present in our body. Myo-inositol is the precursor of inositol triphosphate, a second messenger regulating many hormones such as TSH, FSH and insulin. D-chiro inositol is synthetized by an insulin dependent epimerase that converts myo-inositol into D-chiro-inositol...In [PCOS] patients myo and/or D-chiro-inositol administration improves insulin sensitivity while only myo-inositol is a quality marker for oocytes evaluation. Myo-inositol produces second messengers for FSH and glucose uptake, while D-chiro inositol provides second messengers promoting glucose uptake and glycogen synthesis. The physiological ratio of these two isomers is 40:1 (MI/DCI) and seems to be an optimal approach for the treatment of PCOS disorders.
d-chiro inositol

Gynecol Endocrinol. 2014 Jun;30(6):438-43. doi: 10.3109/09513590.2014.897321. Epub 2014 Mar 7. Modulatory role of D-chiro-inositol (DCI) on LH and insulin secretion in obese PCOS patients. Genazzani AD1, Santagni S, Rattighieri E, Chierchia E, Despini G, Marini G, Prati A, Simoncini T. PMID: 24601829
...Since it has been demonstrated a high incidence of insulin resistance in PCOS patients, our study aimed to evaluate the efficacy of the integrative treatment with D-chiro-inositol (DCI) (500 mg die, per os, for 12 weeks) on hormonal parameters and insulin sensitivity in a group of overweight/obese PCOS patients (body mass index; BMI > 26). After the treatment, interval several endocrine parameters improved (luteinizing hormone [LH], LH/follicle stimulating hormone [FSH], androstenedione and insulin), insulin response to oral glucose tolerance test reported the significant improvement of insulin sensitivity as well as the gonadotropin-releasing hormone (GnRH)-induced (10 µg, in bolus) LH response. BMI decreased, though no lifestyle modification was requested. When data were analyzed according to the presence or absence of first-grade diabetic relatives, PCOS patients with diabetic relatives showed greater improvement after DCI administration. In conclusion DCI administration is effective in restoring better insulin sensitivity and an improved hormonal pattern in obese hyperinsulinemic PCOS patients, in particular, in hyperinsulinemic PCOS patients who have diabetic relatives.
Arch Gynecol Obstet. 2014 Nov 22. [Epub ahead of print] Evaluation of ovarian function and metabolic factors in women affected by polycystic ovary syndrome after treatment with D-Chiro-Inositol. Laganà AS1, Barbaro L, Pizzo A. PMID: 25416201
...We enrolled 48 patients, with homogeneous bio-physical characteristics, affected by PCOS and menstrual irregularities. These patients underwent treatment with 1 gr of D-Chiro-Inositol/die plus 400 mcg of Folic Acid/die orally for 6 months...We evidenced a statistically significant reduction of systolic blood pressure, Ferriman-Gallwey score, LH, LH/FSH ratio, total Testosterone, free Testosterone, ∆-4-Androstenedione, Prolactin, and HOMA Index; in the same patients, we noticed a statistically significant increase of SHBG and Glycemia/IRI ratio. Moreover, we observed statistically significant (62.5 %; p < 0.05) post-treatment menstrual cycle regularization. CONCLUSIONS: D-Chiro-Inositol is effective in improving ovarian function and metabolism of patients affected by PCOS.
Gynecol Endocrinol. 2015 Jan;31(1):52-6. doi: 10.3109/09513590.2014.964201. Epub 2014 Sep 30. The menstrual cycle regularization following d-chiro-inositol treatment in PCOS women: a retrospective study. La Marca A1, Grisendi V, Dondi G, Sighinolfi G, Cianci A. PMID: 25268566
...The objective of this study was to retrospectively analyze the effect of DCI on menstrual cycle regularity in PCOS women. This was a retrospective study of patients with irregular cycles who were treated with DCI. Of all PCOS women admitted to our centre, 47 were treated with DCI and had complete medical charts. The percentage of women reporting regular menstrual cycles significantly increased with increasing duration of DCI treatment (24% and 51.6% at a mean of 6 and 15 months of treatment, respectively). Serum AMH levels and indexes of insulin resistance significantly decreased during the treatment. Low AMH levels, high HOMA index, and the presence of oligomenorrhea at the first visit were the independent predictors of obtaining regular menstrual cycle with DCI. In conclusion, the use of DCI is associated to clinical benefits for many women affected by PCOS including the improvement in insulin resistance and menstrual cycle regularity. Responders to the treatment may be identified on the basis of menstrual irregularity and hormonal or metabolic markers.
myo-inositol 

Gynecol Endocrinol. 2014 Sep 26:1-5. [Epub ahead of print] Ovulation induction with myo-inositol alone and in combination with clomiphene citrate in polycystic ovarian syndrome patients with insulin resistance. Kamenov Z1, Kolarov G, Gateva A, Carlomagno G, Genazzani AD. PMID: 25259724
...The aim of the present study is to evaluate the effectiveness of myo-inositol alone or in combination with clomiphene citrate for (1) induction of ovulation and (2) pregnancy rate in anovulatory women with PCOS and proven insulin resistance. Patients and methods: This study included 50 anovulatory PCOS patients with insulin resistance. All of them received myo-inositol during three spontaneous cycles. If patients remained anovulatory and/or no pregnancy was achieved, combination of myo-inositol and clomiphene citrate was used in the next three cycles. Ovulation and pregnancy rate, changes in body mass index (BMI) and homeostatic model assessment (HOMA) index and the rate of adverse events were assessed. Results: After myo-inositol treatment, ovulation was present in 29 women (61.7%) and 18 (38.3%) were resistant. Of the ovulatory women, 11 became pregnant (37.9%). Of the 18 myo-inositol resistant patients after clomiphene treatment, 13 (72.2%) ovulated. Of the 13 ovulatory women, 6 (42.6%) became pregnant. During follow-up, a reduction of body mass index and HOMA index was also observed. Conclusion: Myo-inositol treatment ameliorates insulin resistance and body weight, and improves ovarian activity in PCOS patients.
Gynecol Endocrinol. 2013 Apr;29(4):375-9. doi: 10.3109/09513590.2012.743020. Epub 2013 Jan 22. Endocrine and clinical effects of myo-inositol administration in polycystic ovary syndrome. A randomized study. Artini PG1, Di Berardino OM, Papini F, Genazzani AD, Simi G, Ruggiero M, Cela V. PMID: 23336594
...50 overweight PCOS patients...underwent hormonal evaluations and an oral glucose tolerance test (OGTT) before and after 12 weeks of therapy (Group A (n¼10): MYO 2 g plus folic acid 200 mg every day; Group B (n¼10): folic acid 200 mg every day). Ultrasound examinations and Ferriman-Gallwey score were also performed... RESULTS: After 12 weeks of MYO administration plasma LH, PRL, T, insulin levels and LH/FSH resulted significantly reduced. Insulin sensitivity, expressed as glucose-to-insulin ratio and HOMA index resulted significantly improved after 12 weeks of treatment. Menstrual cyclicity was restored in all amenorrheic and oligomenorrheic subjects. No changes occurred in the patients treated with folic acid. CONCLUSIONS: MYO administration improves reproductive axis functioning in PCOS patients reducing the hyperinsulinemic state that affects LH secretion.
Combined Therapy (MI plus DCI)

J Clin Pharmacol. 2014 Oct;54(10):1079-92. doi: 10.1002/jcph.362. Epub 2014 Jul 18. The rationale of the myo-inositol and D-chiro-inositol combined treatment for polycystic ovary syndrome. Dinicola S1, Chiu TT, Unfer V, Carlomagno G, Bizzarri M. PMID: 25042908
...Two inositol isomers, myo-inositol (MI) and D-chiro-inositol (DCI) have been proven to be effective in PCOS treatment, by improving insulin resistance, serum androgen levels and many features of the metabolic syndrome. However, DCI alone, mostly when it is administered at high dosage, negatively affects oocyte quality, whereas the association MI/DCI, in a combination reproducing the plasma physiological ratio (40:1), represents a promising alternative in achieving better clinical results, by counteracting PCOS at both systemic and ovary level.
Eur Rev Med Pharmacol Sci. 2013 Feb;17(4):537-40. The Combined therapy myo-inositol plus D-Chiro-inositol, in a physiological ratio, reduces the cardiovascular risk by improving the lipid profile in PCOS patients. Minozzi M1, Nordio M, Pajalich R. PMID: 23467955
BACKGROUND: ...The aim of the present study was to evaluate whether the combined therapy myo-inositol plus D-chiro-inositol (in a in a physiological ratio of 40:1) improve the metabolic profile, therefore, reducing cardiovascular risk in PCOS patients. PATIENTS AND METHODS: Twenty obese PCOS patients [BMI 33.7 ± 6 kg/m2 (mean ± SD)] were recruited. The lipid profile was assessed by measuring total cholesterol, LDL, HDL and triglycerides before and after 6 months treatment with the combined therapy. Secondary end points included changes in BMI, waist-hip ratio, percentage of body fat, HOMA-IR and blood pressure. RESULTS: The combined therapy myo-inositol and D-chiro-inositol improved LDL levels (3.50 ± 0.8 mmol/L versus, 3 ± 1.2 mmol/L p < 0.05), HDL (1.1 mmol/L ± 0.3 versus 1.6 mmol/L ± 0.4 p < 0.05) and triglycerides (2.3 ± 1.5 mmol/L versus 1.75 ± 1.9 mmol/L p < 0.05). Furthermore, significant improvements in HOMA-IR were also observed. CONCLUSIONS: The combined therapy myo-inositol plus D-chiro-inositol is able to improve the metabolic profile of PCOS women, therefore, reducing the cardiovascular risk.
Monotherapy vs. Combined Therapy

Eur Rev Med Pharmacol Sci. 2012 May;16(5):575-81. The combined therapy with myo-inositol and D-chiro-inositol reduces the risk of metabolic disease in PCOS overweight patients compared to myo-inositol supplementation alone. Nordio M1, Proietti E. PMID: 22774396
...In this study, we aim to verify whether the two molecules have a synergistic action by acting on their specific cellular pathways. The effectiveness in reducing the risk of metabolic syndrome as well as in enhancing the ovarian functions of a combined therapy with MI and DCI was compared to a mono therapy in a randomized controlled trial. METHODS: Fifty overweight women with PCOS were enrolled and divided in two groups to receive MI and DCL (MI+DCI group) or MI alone (MI group) for a period of six months. Baseline measurements were repeated at three months (T1) and at the end of the treatment (T2). RESULTS: At the end of the treatment, both MI and MI+DCI groups showed an improvement of the metabolic parameters and no significant differences were found. As expected, the combined supplementation with MI and DCI resulted to be more effective, compared to the MI group, after three months of treatment. CONCLUSIONS: The combined administration of MI and DCI in physiological plasma ratio (40:1) should be considered as the first line approach in PCOS overweight patients, being able to reduce the metabolic and clinical alteration of PCOS and, therefore, reduce the risk of metabolic syndrome.
Arch Gynecol Obstet. 2013 Dec;288(6):1405-11. doi: 10.1007/s00404-013-2855-3. Epub 2013 May 25. The combined therapy myo-inositol plus D-chiro-inositol, rather than D-chiro-inositol, is able to improve IVF outcomes: results from a randomized controlled trial. Colazingari S1, Treglia M, Najjar R, Bevilacqua A. PMID: 23708322
PURPOSE: The present study aims to investigate the effects of the combined therapy myo-inositol (MI) plus D-chiro-inositol (DCI) or D-chiro-inositol treatment in oocyte quality. METHODS: Polycystic ovary syndrome (PCOS) women undergoing IVF-ET were treated with myo-inositol combined with D-chiro-inositol in the physiological ratio (1.1 g myo-inositol plus 27.6 mg of D-chiro-inositol; INOFOLIC combi Lo.Li.pharma) or D-chiro-inositol alone (500 mg; Interquim, s.a., Barcelona, Spain) to evaluate the umber of morphological mature oocytes, total International Units (IU) of recombinant FSH administered and the number of grade 1 embryos. RESULTS: The data clearly showed that only the combined therapy was able to improve oocyte and embryo quality, as well as pregnancy rates, in PCOS women undergoing IVF-ET. CONCLUSION: The present paper further supports the hypothesis that MI plays a crucial role in the ovary in PCOS women. In particular, due to the physiological role played by MI and DCI, the combined therapy should represent a better choice.

Monday, December 22, 2014

Happy Holidays

Image by Viggo Johanson,Wikimedia Commons
I'm taking some much-needed time off to spend with my family during the holiday, so the blog will be taking a brief break.

I hope you have a wonderful Christmas (or whatever holiday you celebrate). Many blessings to you and yours!

Friday, December 12, 2014

Honey for Cesarean Wound Healing?


We've discussed honey for wound healing before, and specifically for cesarean wound healing.

We talked about the mechanics of how honey (medical grade honey, not supermarket honeymight help healing and what studies there were on the topic.

As one review notes:
Honey has anti-oxidant, anti-bacterial and anti-inflammatory properties. It can be used as a wound dressing to promote rapid and improved healing. These effects are due to honey's anti-bacterial action, secondary to its high acidity, osmotic effect, anti-oxidant content and hydrogen peroxide content. The use of honey leads to improved wound healing in acute cases, pain relief in burn patients and decreased inflammatory response in such patients...There is biological plausibility.
Mixed Results

While honey has "biological plausibility" as a healing agent, results from use of medical grade honey have been encouraging in some situations and discouraging in others. Results were not very good for venous ulcers, for example, but on some wounds there are better results.

A recent Cochrane review found decidedly mixed results, depending on what type of wound was being studied, and cautioned against its routine use until more data is available. So it's hard to know just how useful medical grade honey really is, and how much is just hype.

The problem is that much of the honey-based research is sponsored by the companies that make medical-grade honey, so the results are at high risk for bias.

Bottom line.....better data is needed. But given the positive results in some studies and its relatively low cost, why haven't there been more well-controlled studies done by independent groups by now?

Medical-Grade Honey for Cesarean Healing

Sadly, there's not a lot of data on using honey for cesarean wound healing. There are a couple of older studies done in third-world countries, but they had small data sets and uncontrolled conditions. As a result, using medical honey on a cesarean wound has not been been embraced in Western countries.

Now there's a new study on the use of honey for abdominal wound healing after cesarean. The data set is still very small and still from a third-world country, but at least the study design is randomized and blinded. The results from this study were encouraging.

This doesn't prove honey is a healing agent of choice for cesarean wounds, but it certainly points to the need for bigger and better studies to further examine the question. 

I would particularly like to see medical-grade honey investigated in the treatment of cesarean wound infections of "obese" women (who are substantially more at-risk for wound infection than other women).

About 15-30% of high-BMI women will experience a wound infection after a cesarean, and sometimes these infections last for months. Wound infections like this can be devastating to a new mother, can interfere with breastfeeding, and are costly to treat.

Many cesarean wound infections in obese women can likely be lowered by using more appropriate dosages of antibiotics, but medical grade honey might give another weapon in the arsenal against infections in this group of women.

Of course, the best treatment is prevention of the cesareans in the first place whenever possible, which is why the 40-80% cesarean rate in "morbidly" and "super obese" women is so completely unacceptable.

But sometimes cesareans truly are necessary. When cesareans do occur in this group of women, more tools are needed to help prevent or treat the wound infections that will result in some of them.

Medical-grade honey might be yet another tool in the toolbox for this situation. And it's past time for Western medicine to investigate this possibility more thoroughly.


Reference

Oman Med J. 2014 Jul;29(4):255-9. doi: 10.5001/omj.2014.68. The effect of honey gel on abdominal wound healing in cesarean section: a triple blind randomized clinical trial. Nikpour M1, Shirvani MA2, Azadbakht M3, Zanjani R4, Mousavi E5. PMID: 25170405
OBJECTIVE: To assess whether honey can accelerate the wound healing in women undergoing cesarean section. METHODS: This was a triple blinded randomized prospective clinical trial. Women with cesarean section were randomly designated as drug (37 cases) and placebo (38 cases) groups. The drug group received local honey gel 25% while the placebo group received similar free-honey gel on abdominal cesarean incision twice a day for 14 days. REEDA scale (Redness, Edema, Ecchymosis, Discharge and Approximation of wound edges) was used to assess wound healing. RESULTS: The mean REEDA was 2.27 ± 2.46 and 3.91 ± 2.74 (p=0.008) on the 7(th) day and 0.47 ± 0.84 and 1.59± 1.95 (p=0.002) on the 14(th) day for the drug and placebo groups, respectively. Redness, edema and hematoma in the drug group were significantly lower on the 7(th) and 14(th) days. CONCLUSION: Honey was effective in healing the cesarean section incision. Using topical honey is suggested as a natural product with rare side effects in order to reduce the complications of cesarean wounds.