The Association between Maltreatment in Childhood and Pre-Pregnancy Obesity in Women Attending an Antenatal Clinic in Australia

Introduction

Obesity in pregnancy is associated with increased risk of complications and adverse outcomes in mother and child. Childhood adverse experiences are known to have numerous negative physical and emotional sequelae. We aimed to examine if exposure to abuse and/or neglect in childhood increased the likelihood of pre-pregnancy obesity.

Methods

Demographic and clinical data including weight, height, mental health as measured by the General Health Questionnaire and exposure to childhood trauma as measured by the childhood trauma questionnaire was collected from 239 women attending antenatal care at an Australian tertiary hospital.

Results

More than one quarter of women were obese prior to pregnancy and approximately 20% of women self reported experiencing moderate to severe physical, sexual or emotional abuse. Almost 60% of women scored in the clinical range on the GHQ. Pre-pregnancy obesity in women attending antenatal care was associated with a self-reported history of emotional or physical abuse with those exposed to moderate or severe emotional or physical abuse having increased odds of being obese prior to pregnancy (O.R. and 95% CI: 2.40; 1.19–4.84 and 2.38; 1.18–4.79 respectively). There was no significant association between other forms of childhood maltreatment, demographic or current mental health status and pre-pregnancy obesity.

Conclusions

The high rates of obesity, mental health problems and self reported childhood maltreatment in the Australian antenatal population are serious public health concerns due to the extra health risks conferred on mother and offspring. Exposure to physical or emotional abuse during childhood increases the likelihood of obesity in women attending antenatal care. Further research is required to determine reasons for this association.     

Childhood Growth Trajectories According to Combinations of Pregestational Weight Status and Maternal Smoking during Pregnancy: A Multilevel Analysis

Pregestational weight status and maternal smoking during pregnancy are significantly associated with fetal and childhood growth. However, few studies have examined associations between childhood growth and combinations of these factors using multilevel analysis. This study aimed to describe differences in childhood growth trajectories according to these combinations, using data from a prospective cohort study in Japan. The study participants were 1,973 women and their singletons, who were born between April 1, 1991 and March 31, 2003. Children were categorized according to whether they were born to normal-weight, nonsmoking mothers (NN); normal-weight, smoking mothers (NS); underweight, nonsmoking mothers (UN); underweight, smoking mothers (US); overweight, nonsmoking mothers (ON); or overweight, smoking mothers (OS). Birth weight and anthropometric data were collected from 1,965 children at birth (99.6%), 1,655 aged 3 (83.9%), 1,527 aged 5 (77.4%), 1,497 aged 7–8 (75.9%), and 1,501 aged 9–10 (76.1%). Multilevel analysis examining both individual and age as different level variables according to sex was used to describe the trajectories of body mass index z scores for statistical analyses. Although children of the OS group were the leanest at birth, their body mass indices had increased rapidly by 3 years of age. Moreover, body mass index was also likely to increase in boys in the NS and ON groups. A different trend was observed in girls. Body mass index decreased from 5 years of age in girls in the US group. There were no remarkable differences in body mass index trajectories between children in the other groups. In conclusion, childhood growth trajectories differed according to combinations of pregestational weight status and maternal smoking during pregnancy. Further, there were sex-related differences in the associations between childhood growth and factor combinations.     

Association of Childhood Physical and Sexual Abuse with Intimate Partner Violence,Poor General Health and Depressive Symptoms among Pregnant Women

ObjectiveWe examined associations of childhood physical and sexual abuse with risk of intimate partner violence (IPV). We also evaluated the extent to which childhood abuse was associated with self-reported general health status and symptoms of antepartum depression in a cohort of pregnant Peruvian women.MethodsIn-person interviews were conducted to collect information regarding history of childhood abuse and IPV from 1,521 women during early pregnancy. Antepartum depressive symptomatology was evaluated using the Patient Health Questionnaire-9. Multivariable logistic regression procedures were used to estimate adjusted odds ratios (aOR) and 95% confidence intervals (95%CI).ResultsAny childhood abuse was associated with 2.2-fold increased odds of lifetime IPV (95%CI: 1.72–2.83). Compared with women who reported no childhood abuse, those who reported both, childhood physical and sexual abuse had a 7.14-fold lifetime risk of physical and sexual IPV (95%CI: 4.15–12.26). The odds of experiencing physical and sexual abuse by an intimate partner in the past year was 3.33-fold higher among women with a history of childhood physical and sexual abuse as compared to women who were not abused as children (95%CI 1.60–6.89). Childhood abuse was associated with higher odds of self-reported poor health status during early pregnancy (aOR = 1.32, 95%CI: 1.04–1.68) and with symptoms of antepartum depression (aOR = 2.07, 95%CI: 1.58–2.71).ConclusionThese data indicate that childhood sexual and physical abuse is associated with IPV, poor general health and depressive symptoms in early pregnancy. The high prevalence of childhood trauma and its enduring effects of on women’s health warrant concerted global health efforts in preventing violence.     

The role of oral glucose intolerance test in reducing pregnancy complications

The influence of glucose monitoring during pregnancy on newborn body weight, and complications during pregnancy and labor was assessed. We performed a retrospective analysis of macrosomal children, fetal growth, caesarean sections, malformations, still-births and the number of oral glucose tolerance test (OGTT) carried out in a five-year period. The proportion of women participating in OGTT tests increased from 20% to 40% (p<0.05) between 2000 and 2004. Gestation diabetes mellitus (GDM) proportions among pregnant women seen at the Department of Obstetrics and Gynecology at Slavonski Brod General Hospital, Croatia increased from 1% to 6.7% (p < 0. 05) during the observed period. Proportion of births identified as macrosomal decreased from 13.3% to 12.2% (p<0.05). Additionally, infant mortality and still-births along with other fetal and maternal complications declined during the same period. These results suggest that regular measurements of glucose tolerance during pregnancy may prevent preterm birth, decrease the proportion of macrosomal newborns, lower mortality and decrease fetal and maternal complication incidence during pregnancy and delivery.     

Pre-pregnancy risk assessment and counselling of the cardiac patient

Pregnant women with heart disease often have an increased risk of maternal cardiovascular and offspring complications. The magnitude of these risks varies depending on the type and severity of the underlying disease. Therefore risk assessment should be performed before pregnancy. This can be accomplished by taking into account predictors and risk scores that have been developed in large populations of pregnant women with heart disease, as well as by consulting disease-specific pregnancy literature. A system that integrates all available knowledge about the risk of pregnancy is the adapted World Health Organisation risk classification. The safety of pregnancy for women with heart disease can be enhanced by adequate risk assessment and counselling.     

Health perceptions and demographic characteristics associated with underassessment of body weight

Objectives: To describe the relationship between BMI and perceived weight status and to determine how underassessment of weight status is associated with demographic characteristics, self‐reported general health, and perceived health risk in relation to one's body weight. Methods and Procedures: In the 2004 Styles surveys, 3,888 US adult participants described their current weight status (underweight, about right, slightly overweight, very overweight), which we compared with self‐reported BMI in order to determine concordance. We used multivariable logistic regression to evaluate associations between underassessment of body weight and characteristics of interest. Results: Among persons with a BMI ≥25, women were more likely than men to recognize their overweight status (slightly or very overweight; 93.0% of women vs. 73.5% of men) and the extent to which they were overweight: 70.4% of obese women vs. 49.5% of obese men described themselves as very overweight. Among the overweight and obese of both sexes, disagreement with regard to current weight as a health risk was associated with underassessment of weight. Additional factors associated with underassessment were education and race/ethnicity among overweight women; race/ethnicity among overweight men; household income and self‐rated health among obese women; and self‐rated health among obese men (P < 0.05). Discussion: While most of the obese participants recognized that they were overweight, many of them, particularly among the men, did not realize the extent to which they were overweight. Public health messages may be more effective if they are specifically tailored to target audiences, besides emphasizing the health risks associated with excess body weight.     

Physical Activity Patterns in Normal-Weight and Overweight/Obese Pregnant Women

The aims of the present study were to assess the volume of physical activity (PA) throughout pregnancy in normal-weight vs overweight/obese women, and to investigate which factors may predict compliance to PA recommendations in these women throughout gestation. In 236 pregnant women, 177 normal-weight and 59 overweight/obese (median[IQR] BMI 21.2[19.9–22.8] vs 26.5[25.5–29.0] kg/m2, respectively), medical history, anthropometry and clinical data, including glucose tolerance, were recorded. In addition, pre-pregnancy PA was estimated by the Kaiser questionnaire, while total, walking and fitness/sport PA during pregnancy were assessed by the Physical Activity Scale for the Elderly (PASE) modified questionnaire, at 14–16, 24–28 and 30–32 weeks of gestation. PA volume was very low in the first trimester of pregnancy in both groups of women. However, it increased in the second and third trimester in normal-weight, but not in overweight/obese subjects. Higher pre-pregnancy PA was a statistically significant predictor of being physically active (>150 minutes of PA per week) during all trimesters of gestation. In conclusion, physical activity volume is low in pregnant women, especially in overweight/obese subjects. PA volume increases during pregnancy only in normal-weight women. Pre-pregnancy PA is an independent predictor of achieving a PA volume of at least 150 min per week during pregnancy.     

Chikotsa--secrets, silence, and hiding: social risk and reproductive vulnerability in central Mozambique

In this article, I examine pregnancy narratives and patterns of reproductive health seeking among women of fertile age in central Mozambique. I map the interplay between gendered economic marginalization, maternal risk perceptions, and pregnancy management strategies. By interpreting my data in light of Shona illness theories, I illuminate the ways that embodied experiences of reproductive vulnerability, risk perceptions, and social inequalities are linked: women attribute the most serious maternal complications to human- or spirit-induced reproductive threats of witchcraft and sorcery. This construction of reproductive vulnerability as social threats related to material and social competition significantly influences prenatal health seeking. Data reveal the structural and cognitive gap between biomedical constructions of risk and lay social threat perceptions. Plural health care systems are strategically utilized by women seeking to minimize both social and biological harm. On-the-ground ethnography shows that maternal health initiatives must take this plurality into full and accommodative account to achieve viable improvements in reproductive care and outcomes.     

Pregnancies in women with and without renal scarring after urinary infections in childhood.

OBJECTIVE--To compare the outcome of pregnancy in women with and without renal scarring after childhood urinary infections with that in unmatched controls. DESIGN--Retrospective study of pregnancies in women prospectively followed up from their first recognised urinary infection. SETTING--Tertiary referral centre in Gothenburg. SUBJECTS--111 Women attending an outpatient clinic for women with urinary infection during 1975-83, of whom 41 (65 pregnancies) were studied (19 women with renal scarring (32), 22 without scarring (33)), and 65 controls (65) randomly selected and matched for parity, age, smoking habits, and date of delivery. MAIN OUTCOME MEASURES--Urinary infections and complications in pregnancy. RESULTS--The incidence of bacteriuria during first pregnancies was significantly greater in women with (9, 47%) and without (6, 27%) renal scarring after childhood urinary infection than in controls (1, 2%) (p less than 0.001, 0.01 respectively). Symptomatic infections were seen only among women with a history of urinary infection: four women with renal scarring (three of whom had vesicoureteric reflux) developed pyelonephritis and three cystitis, and one woman without scarring developed pyelonephritis. Mean blood pressure was higher among women with severe renal scarring than controls (4/11 v 3/44; p less than 0.05) before and during pregnancy. There was no significant difference in the incidence of pre-eclampsia, operative delivery, prematurity, or birth weight. CONCLUSIONS--Women with a history of previous urinary infections had a high incidence of bacteriuria during pregnancy, and those with renal scarring and persistent reflux were prone to develop acute pyelonephritis. The risk of serious complications in pregnancy, however, was not increased in women with severe renal scarring, possibly owing to their continuous clinical supervision.     

Maternal use of selective serotonin re-uptake inhibitors in early pregnancy and infant congenital malformations

BACKGROUND: Maternal use of selective serotonin re-uptake inhibitors (SSRIs) has recently been associated with an increased risk for certain malformations. METHODS: Using the Swedish Medical Birth Register, we identified women who had reported the use of SSRIs in early pregnancy and studied their infants, born between July 1, 1995 and the end of 2004. Congenital malformations were identified from that register, from the Register of Congenital Malformations, and from the Hospital Discharge Register. The effect of drug exposure was studied after adjustment for a number of identified maternal characteristics that could act as confounders. RESULTS: We identified 6,481 women who reported the use of SSRIs in early pregnancy and their 6,555 infants. There was no general increase in malformation risk. An increased risk for cystic kidneys was seen, but this was based on only nine malformed infants, and the pathology varied between these cases. An in-depth study of cardiovascular defects identified an association between such defects and notably ventricular and atrial septum defects and maternal use of paroxetine but not other SSRIs. No support for a postulated association between SSRI use and infant craniostenosis or omphalocele was found. CONCLUSIONS: Use of SSRIs in early pregnancy does not seem to be a major risk factor for infant malformations. The association between paroxetine use and infant cardiovascular defects may be a result of multiple testing, but is supported by other studies.     

Maternal and Neonatal Outcomes among Pregnant Women with 2009 Pandemic Influenza A(H1N1) Illness in Florida, 2009-2010: A Population-Based Cohort Study

Introduction

Pregnant women have been identified as a high risk group for severe illness with 2009 pandemic influenza A(H1N1) virus infection (pH1N1). Obesity has also been identified as a risk factor for severe illness, though this has not been thoroughly assessed among pregnant women. The objectives of this study were to provide risk estimates for adverse maternal and neonatal outcomes associated with pH1N1 illness during pregnancy and to assess the role of obesity in these outcomes.

Methods

We established a retrospective population-based cohort of all live births occurring in Florida during the first 15 months of the pandemic. Illness with pH1N1 during pregnancy was ascertained through record linkage with the Florida state notifiable disease surveillance database. Data from the birth record, including pre-pregnancy body mass index, were analyzed to assess risk of adverse outcomes associated with pH1N1 illness.

Results

A total of 194 women were identified through surveillance with pH1N1 illness during pregnancy. Children born to women with pH1N1 illness during pregnancy were at increased risk for low birth weight [OR (95%CI): 1.78 (1.11-2.860)], premature birth [2.21 (1.47-3.330)], and infant death [4.46 (1.80-11.00)], after adjusting for other factors. Women with pH1N1 illness during pregnancy were at increased risk for severe outcomes including admission to an intensive care unit. Obesity was an observed risk factor, both for the more severe pH1N1 illness detected through surveillance, and for severe maternal outcomes.

Conclusions

Case-patients in this analysis likely represent the most severely ill subset of all women infected with pH1N1 during pregnancy, limiting the generalizability of these findings to more severely ill patients rather than influenza infection in general. Nevertheless, these results suggest that more severe pH1N1 illness during pregnancy is associated with adverse neonatal outcomes and that pregnant women should continue to be targeted for appropriate prophylaxis and early treatment.     

Severe Obesity in Young Women and Reproductive Health: The Danish National Birth Cohort

Background

Little is known about reproductive health in severely obese women. In this study, we present associations between different levels of severe obesity and a wide range of health outcomes in the mother and child.

Methods

From the Danish National Birth Cohort, we obtained self-reported information about prepregnant body mass index (BMI) for 2451 severely obese women and 2450 randomly selected women from the remaining cohort who served as a comparison group. Information about maternal and infant outcomes was also self-reported or came from registers. Logistic regression was used to estimate the association between different levels of severe obesity and reproductive outcomes.

Principal Findings

Subfecundity was more frequent in severely obese women, and during pregnancy, they had an excess risk of urinary tract infections, gestational diabetes, preeclampsia and other hypertensive disorders which increased with severity of obesity. They tended to have a higher risk of both pre- and post-term birth, and risk of cesarean and instrumental deliveries increased across obesity categories. After birth, severely obese women more often failed to initiate or sustain breastfeeding. Risk of weight retention 1.5 years after birth was similar to that of other women, but after adjustment for gestational weight gain, the risk was increased, especially in women in the lowest obesity category. In infants, increasing maternal obesity was associated with decreased risk of a low birth weight and increased risk of a high birth weight. Estimates for ponderal index showed the same pattern indicating an increasing risk of neonatal fatness with severity of obesity. Infant obesity measured one year after birth was also increased in children of severely obese mothers.

Conclusion

Severe obesity is correlated with a substantial disease burden in reproductive health. Although the causal mechanisms remain elusive, these findings are useful for making predictions and planning health care at the individual level.     

Implications of childhood obesity for adult health: findings from thousand families cohort study

ObjectiveTo determine whether being overweight in childhood increases adult obesity and risk of disease.DesignProspective cohort study.SettingCity of Newcastle upon Tyne.Participants932 members of thousand families 1947 birth cohort, of whom 412 attended for clinical examination age 50.ResultsBody mass index at age 9 years was significantly correlated with body mass index age 50 (r=0.24, P<0.001) but not with percentage body fat age 50 (r=0.10, P=0.07). After adult body mass index had been adjusted for, body mass index at age 9 showed a significant inverse association with measures of lipid and glucose metabolism in both sexes and with blood pressure in women. However, after adjustment for adult percentage fat instead of body mass index, only the inverse associations with triglycerides (regression coefficient= −0.21, P<0.01) and total cholesterol (−0.17, P<0.05) in women remained significant.ConclusionsLittle tracking from childhood overweight to adulthood obesity was found when using a measure of fatness that was independent of build. Only children who were obese at 13 showed an increased risk of obesity as adults. No excess adult health risk from childhood or teenage overweight was found. Being thin in childhood offered no protection against adult fatness, and the thinnest children tended to have the highest adult risk at every level of adult obesity.

What is already known on this topic

Many studies have found that body mass index in childhood is significantly correlated with body mass index in adulthoodObese children have been found to have higher all cause mortality as adults

What this study adds

No excess health risk from childhood overweight was foundChildhood body mass index was linked to adulthood body mass index but not percentage body fatOnly children who were obese at 13 showed a significant increased risk of obesity as adultsPeople who were thinnest as children and fattest as adults tended to have the highest adult risk     

Examining the Impact of a Public Health Message on Fish Consumption in Bermuda

Background

In 2003 mean cord blood mercury concentrations in pregnant Bermudian women exceeded levels associated with adverse health outcomes in children. The principal mercury source was local fish species. Public health messages were developed suggesting pregnant women reduce consumption of fish species with higher mercury concentrations (e.g. swordfish), substituting species containing lower mercury concentrations, and elevated omega-3 fatty acids (e.g. anchovies). Recent evidence indicates mercury concentrations in Bermuda’s pregnant women have fallen five- fold.

Objectives

Assess whether changes in women’s fish eating patterns during pregnancy are consistent with the public health messaging. Determine who is making changes to their diet during pregnancy and why.

Methods

Mixed methods study with a cross-sectional survey of 121 pregnant women, including 13 opened-ended interviews. Health system, social vulnerability, public health messaging, and socio-demographic variables were characterized and related to changes in fish consumption during pregnancy. Qualitative data were coded according to nutritional advice messages, comprehension of communication strategies, and sources of information.

Results

95% of women surveyed encountered recommendations about fish consumption during pregnancy. 75% reported modifying fish eating behaviors because of recommendations. Principal sources of information about fish consumption in pregnancy were health care providers and the Internet. 71% of women reported reducing consumption of large fish species with greater mercury levels, but 60% reported reduced consumption of smaller, low mercury fish. No participant mentioned hearing about the benefits of fish consumption. More frequent exposure to public health messages during pregnancy was associated with lower reported consumption. Bermudian born women were less likely to reduce consumption of large fish species during pregnancy.

Conclusions

In Bermuda, public health messages advocating reduced consumption of larger, higher mercury-containing fish species appear effective, but masked the nutritional value message of small fish species, with low mercury concentration. Adjustment is needed to better balance the risk communication.     

HIV and the Risk of Direct Obstetric Complications: A Systematic Review and Meta-Analysis

Background

Women of reproductive age in parts of sub-Saharan Africa are faced both with high levels of HIV and the threat of dying from the direct complications of pregnancy. Clinicians practicing in such settings have reported a high incidence of direct obstetric complications among HIV-infected women, but the evidence supporting this is unclear. The aim of this systematic review is to establish whether HIV-infected women are at increased risk of direct obstetric complications.

Methods and findings

Studies comparing the frequency of obstetric haemorrhage, hypertensive disorders of pregnancy, dystocia and intrauterine infections in HIV-infected and uninfected women were identified. Summary estimates of the odds ratio (OR) for the association between HIV and each obstetric complication were calculated through meta-analyses. In total, 44 studies were included providing 66 data sets; 17 on haemorrhage, 19 on hypertensive disorders, five on dystocia and 25 on intrauterine infections. Meta-analysis of the OR from studies including vaginal deliveries indicated that HIV-infected women had over three times the risk of a puerperal sepsis compared with HIV-uninfected women [pooled OR: 3.43, 95% confidence interval (CI): 2.00–5.85]; this figure increased to nearly six amongst studies only including women who delivered by caesarean (pooled OR: 5.81, 95% CI: 2.42–13.97). For other obstetric complications the evidence was weak and inconsistent.

Conclusions

The higher risk of intrauterine infections in HIV-infected pregnant and postpartum women may require targeted strategies involving the prophylactic use of antibiotics during labour. However, as the huge excess of pregnancy-related mortality in HIV-infected women is unlikely to be due to a higher risk of direct obstetric complications, reducing this mortality will require non obstetric interventions involving access to ART in both pregnant and non-pregnant women.     

Epidemiological evidence for the role of physical activity in reducing risk of type 2 diabetes and cardiovascular disease.

Epidemiological studies suggest that physically active individuals have a 30-50% lower risk of developing type 2 diabetes than do sedentary persons and that physical activity confers a similar risk reduction for coronary heart disease. Risk reductions are observed with as little as 30 min of moderate-intensity activity per day. Protective mechanisms of physical activity include the regulation of body weight; the reduction of insulin resistance, hypertension, atherogenic dyslipidemia, and inflammation; and the enhancement of insulin sensitivity, glycemic control, and fibrinolytic and endothelial function. Public health initiatives promoting moderate increases in physical activity may offer the best balance between efficacy and feasibility to improve metabolic and cardiovascular health in largely sedentary populations.     

Risk of Inflammatory Bowel Disease According to Self-Rated Health,Pregnancy Course,and Pregnancy Complications: A Study within the Danish National Birth Cohort

Background

Poor self-rated health (SRH) has been connected to immunological changes, and pregnancy complications have been suggested in the etiology of autoimmune diseases including inflammatory bowel disease (IBD). We evaluated the impact of self-rated pre-pregnancy health and pregnancy course, hyperemesis, gestational hypertension, and preeclampsia on risk of IBD.

Methods

Information was collected by questionnaires from The Danish National Birth Cohort (enrolment 1996–2002) at 16^th and 30^th week of pregnancy and 6 months postpartum. A total of 55,699 women were followed from childbirth until development of IBD (using validated National Hospital Discharge Register diagnoses), emigration, death, or end of follow-up, 31^st of October, 2011. Hazard ratios (HR) with 95% confidence intervals (CI) were calculated using Cox proportional hazards models adjusting for age and evaluating pre-pregnancy BMI, parity, alcohol and tobacco consumption, and socio-occupational status as potential confounders.

Results

Risk of IBD increased with decreasing level of self-rated pre-pregnancy health (p = 0.002) and was elevated in women with poor self-rated pregnancy course (HR, 1.61, 95% CI 1.22–2.12). Associations persisted for more than 5 years postpartum. Hyperemesis and preeclampsia were not significantly associated with risk of IBD.

Conclusions

This is the first prospective observational study to suggest that poor self-rated health – in general and in relation to pregnancy – is associated with increased risk of IBD even in the long term though results needs further confirmation. Symptoms of specific pregnancy complications were, on the other hand, not significantly associated with risk of IBD.     

The gender differences in health effects of environmental cadmium exposure and potential mechanisms

On a viewpoint of gender differences in Cd body burden and its health effects, we reviewed the population-based research including our own which conducted in Japan, Thailand, Australia, Poland, Belgium and Sweden to assess health effects of human exposure to environmental cadmium and their potential mechanisms. As a result, six risk factors in Cd health effects in women have been identified; (1) more serious type of renal tubular dysfunction, (2) difference in calcium metabolism and its regulatory hormones, (3) kidney sensitivity; difference in P450 phenotype, (4) pregnancy, (5) body iron store status, and (6) genetic factors. Further studies of Cd toxicity targeted to women would now appear necessary.     

Gender Differences in Body Satisfaction

PINGITORE, REGINA, BONNIE SPRING, DAVID GARFIELD. Gender differences in body satisfaction. Although men and women show similar rates of obesity, women more frequently engage in weight loss efforts, with potentially adverse health consequences. We surveyed 320 college-aged men and women to examine gender differences in the determinants of body dissatisfaction and the degree of importance assigned to body-weight and shape. Results indicated that, for both genders, satisfaction with bodyweight and shape decreased as body mass index (BMI) increased. Women, however, showed significantly greater body and weight dissatisfaction than men at most weight categories. Only the underweight (BMI<20) women and men were similarly satisfied with their bodyweight and shape. As BMI increased, however, women became disproportionately more dissatisfied: both normal-weight and overweight women expressed greater dissatisfaction than comparable men. College-aged women also attributed progressively more importance to both weight and shape as BMI increased, unlike college-aged men, who considered body weight equally important to (or slightly less important than) self-esteem as BMI increased. We discuss implications for the self-esteem of obese women and men.     

Effect of obesity on flap and donor-site complications in free transverse rectus abdominis myocutaneous flap breast reconstruction

The purpose of this study was to assess the effect of obesity on flap and donor-site complications in patients undergoing free transverse rectus abdominis myocutaneous (TRAM) flap breast reconstruction. All patients undergoing breast reconstruction with free TRAM flaps at our institution from February 1, 1989, through May 31, 1998, were reviewed. Patients were divided into three groups based on their body mass index: normal (body mass index <25), overweight (body mass index 25 to 29), obese (body mass index > or =30). Flap and donor-site complications in the three groups were compared. A total of 936 breast reconstructions with free TRAM flaps were performed in 718 patients. There were 442 (61.6 percent) normal-weight, 212 (29.5 percent) overweight, and 64 (8.9 percent) obese patients. Flap complications occurred in 222 of 936 flaps (23.7 percent). Compared with normal-weight patients, obese patients had a significantly higher rate of overall flap complications (39.1 versus 20.4 percent; p = 0.001), total flap loss (3.2 versus 0 percent; p = 0.001), flap seroma (10.9 versus 3.2 percent; p = 0.004), and mastectomy flap necrosis (21.9 versus 6.6 percent; p = 0.001). Similarly, overweight patients had a significantly higher rate of overall flap complications (27.8 versus 20.4 percent; p = 0.033), total flap loss (1.9 versus 0 percent p = 0.004), flap hematoma (0 versus 3.2 percent; p = 0.007), and mastectomy flap necrosis (15.1 versus 6.6 percent; p = 0.001) compared with normal-weight patients. Donor-site complications occurred in 106 of 718 patients (14.8 percent). Compared with normal-weight patients, obese patients had a significantly higher rate of overall donor-site complications (23.4 versus 11.1 percent; p = 0.005), infection (4.7 versus 0.5 percent; p = 0.016), seroma (9.4 versus 0.9 percent; p <0.001), and hernia (6.3 versus 1.6 percent; p = 0.039). Similarly, overweight patients had a significantly higher rate of overall donor-site complications (19.8 versus 11.1 percent; p = 0.003), infection (2.4 versus 0.5 percent; p = 0.039), bulge (5.2 versus 1.8 percent; p = 0.016), and hernia (4.3 versus 1.6 percent; p = 0.039) compared with normal-weight patients. There were no significant differences in age distribution, smoking history, or comorbid conditions among the three groups of patients. Obese patients, however, had a significantly higher incidence of preoperative radiotherapy and preoperative chemotherapy than did patients in the other two groups. A total of 23.4 percent of obese patients had preoperative radiation therapy compared with 12.3 percent of overweight patients and 12.4 percent of normal-weight patients; 34.4 percent of obese patients had preoperative chemotherapy compared with 24.5 percent of overweight patients and 17.7 percent of normal-weight patients. Multiple logistic regression analysis was used to determine the risk factors for flap and donor-site complications while simultaneously controlling for potential confounding factors, including the incidence of preoperative chemotherapy and radiotherapy. In summary, obese and overweight patients undergoing breast reconstruction with free TRAM flaps had significantly higher total flap loss, flap hematoma, flap seroma, mastectomy skin flap necrosis, donor-site infection, donor-site seroma, and hernia compared with normal-weight patients. There were no significant differences in the rate of partial flap loss, vessel thrombosis, fat necrosis, abdominal flap necrosis, or umbilical necrosis between any of the groups. The majority of overweight and even obese patients who undertake breast reconstruction with free TRAM flaps complete the reconstruction successfully. Both such patients and surgeons, however, must clearly understand that the risk of failure and complications is higher than in normal-weight patients. Patients who are morbidly obese are at very high risk of failure and complications and should avoid any type of TRAM flap breast reconstruction.