[Editor's note: in this installment of our maternal obesity series, Dr. Kathleen Kendall-Tackett will guide us through a review of maternal obesity as it pertains to breastfeeding. To read this series from the beginning, go here. Tomorrow, we will finish up with some final thoughts from Well Rounded Mama's, Pamela Vireday, on prevention strategies.]

I remember the moment quite clearly. I was at a large, international breastfeeding conference and stopped to read the research posters. As I did, I grew more and more irritated. There were several posters describing special interventions for 'obese women.' Some of these interventions involved sending 'obese women' to breastfeeding classes designed to address their 'special' needs. Excuse me? First of all, the design of these studies appeared to assume that 'obese women' are a homogeneous group, which they obviously are not. Second, why a class? Does the fact that they are heavy mean that they need special instructions? I'm certain that these colleagues meant well, but we have to ask whether this approach is a good idea.

OK, I'll admit it: I'm a radical on this issue. My stand is due, in part, to the treatment that fat people'and fat women, in particular'receive in health care settings. The story goes something like this. Fat girl goes in for a medical exam because she's been having concerning symptoms. Health care provider attributes all her health care problems to her size and sends her away with admonitions to lose weight. Only later, does it turn out that she has something awful, like cancer'a condition her HCPs missed completely because they made assumptions based on her physical appearance. Think I exaggerate? This scenario recently happened to the daughter-in-law of one of my friends.

Yes, but what about diabetes, heart disease, and the increased risk of complications following surgery, you might ask? Fortunately, I actually study diabetes, metabolic syndrome and heart disease. Obviously, health care providers do need to address any increased risk their patients might experience. So if their patients have high blood pressure, triglycerides, or LDL cholesterol, by all means address that. But we need to address those concerns without making sweeping assumptions about women who happen to have a higher BMI. For example, one colleague told me that she tells her obese patients that they need to lay off the soda and potato chips. The question I asked was whether she knew'for sure'that her fat patients were drinking soda and eating potato chips. Or that her slim patients weren't? Did she know this or was she making assumptions based on prejudice against fat people?

Most of the proposed policy changes designed to address the 'obesity epidemic' are, in my opinion, good ideas'for everyone, not just fat people. Get fast food and soda machines out of the schools? Great idea. Encourage more physical activity? Also good. Encourage increased consumption of whole grains, fruits and vegetables instead of highly refined and calorically dense junk food? Fabulous.

These approaches to obesity are all good. But we need to recognize a couple of things. First, even with all these interventions, some people are still going to be bigger than others. That isn't necessarily a health problem. Second, someone can fall into the 'obese' range on the BMI and still have good, sometimes even better cardiovascular health than someone who is smaller. Is size really an indicator of overall health, or is it perhaps simply one marker of many? Further, when someone brings up the issue of obesity to me, one of the first questions I ask in response is 'how obese?' That makes a difference in terms of what type of problems we are likely to encounter. Assuming that all women who cross the 'obesity' threshold have more health problems is simply wrong. Sometimes they do, sometimes they don't. Third, providers sometimes assume that obesity is simply due to eating too much; that it's just a matter of getting these women to take their faces out of the feeding trough. We've learned relatively recently, however, that it's not quite that simple. In the past five years, there have been numerous studies demonstrating the role of depression, psychological trauma (particularly childhood abuse), and sleep disorders in weight gain and obesity. Yes, depression (and trauma and sleep problems) can make you fat. And there is also the matter of genetics. Some people are genetically programmed to be larger than others. Steps that these patients take to improve their health will improve their health. But these interventions may not significantly change their size.

So back to the question of a special breastfeeding gulag for fat girls. These interventions assume that women over a certain BMI will automatically have breastfeeding problems. When I've raised this issue with my colleagues, I've heard arguments about how larger breasts can cause problems, or that fat women have lower prolactin levels after birth. They also assure me that fat women feel more shame about their bodies and will be reluctant to breastfeed when outside their homes, something we know is related to earlier breastfeeding cessation. OK, these things might possibly be problems. But women overcome breastfeeding problems all the time. The question we need to ask is whether we are creating self-fulfilling prophecies about these women. Breastfeeding is largely a confidence game. If we communicate to women that they think they will fail, whether we say this directly, or indirectly by sending them to a special class'¸ are we setting them up for failure? This is a lesson we had to learn about mothers with issues such as flat nipples. Yes, these women can have more problems, but they don't always. When we make flat nipples an issue, and communicate that mothers will likely fail, we can increase the rate of breastfeeding failure.

As for the shame issue, keep in mind that while there are discernable physical markers of obesity (such as BMI), obesity is also a social construct. Not everyone who is fat feels badly about it. In fact, in some ethnic minority populations, fat women are considered attractive. (And from an evolutionary standpoint, carrying some extra poundage is actually a survival advantage.) The question we need to ask is whether obese women with positive body images are having more breastfeeding problems than their smaller peers. I strongly suspect that they are not.

Frankly, it's time for empowered fat girls to speak out on behalf of our sisters who do not yet know that they have a voice. Women of size deserve respectful care, not shaming. Is packing these women off to a breastfeeding fat camp a good idea? Personally, I don't think so. And I can't imagine how you would market these classes to mothers. How many would willingly sign up for classes designated for obese women? ('Oh yes, that's me. Please sign me up!') While we want to proactively address any problems we think that these women may encounter, we need to plan our interventions with circumspection and care. Women of all sizes deserve no less.

Posted by: Kathleen Kendall-Tackett, who is a health psychologist and board-certified lactation consultant. She is a clinical associate professor of pediatrics at the Texas Tech University School of Medicine in Amarillo, Texas. The views expressed in this posting likely do not reflect the official views of the Texas Tech

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