Tackling the Mysteries of Obesity in a Skinny City

There are the fliers on the walls of St. Luke’s Hospital. There are the doctors — the Committee for Human Research has signed off on the study, so doctors can mention it to any patients who seem like they might qualify, and both UCSF and CPMC are collaborating, so that’s a lot of doctors.

The goal: to measure what happens, to both women and their children, when women who meet the NIH standards for being overweight — a body mass index of 25 or higher — participate in a stress-reduction and healthy-eating training during pregnancy. They’ve got the funding to follow these women through their pregnancies, and their children for nine months after birth. It’s not as much as hoped for, but enough for now.

In 1985, fewer than 10 percent of Californians were obese, according to data compiled by the the Center for Disease Control. By 2003 that number had doubled. It’s stayed level since then, but those 13 years remain the source of intense scientific interest. Why did this happen? Was it corn syrup? The end of factory work? Larger portion sizes? And how — because people who are obese are more likely to develop health problems like Type 2 diabetes and hypertension — to undo what happened in those years?

In 2006, the journal Pediatrics published an interesting, if not especially conclusive, study that suggested that the children of women who had undergone weight loss surgery were far less likely to be obese during childhood than siblings born before the surgery. The theory was that perhaps metabolism was less a matter of genetics and more of a dialogue between a mother’s body and the developing fetus. If true, it’s possible that people could break a cycle of obesity by keeping weight off during pregnancy.

Such work can be tricky. The research that could prove such a supposition is still in its early stages. A similar study to the one in San Francisco began last year in Washington and Oregon, organized by Kaiser Permenente. The hypothesis that the study is based on, Barker’s Hypothesis, is named after a British doctor who in the 1990s noted abnormally high rates of heart disease in the poorest areas of Wales and England. His eventual conclusion was that malnutrition caused heart disease. As these adult patients had developed as fetuses, priority went to building a good solid brain, meaning that the results of that compromise showed themselves, years later, in the form of weakened hearts. Not gaining weight won’t be enough on its own, especially since a patient can be obese and malnourished at the same time.

Many obstetricians, says Naomi Stotland, an OB/GYN at UCSF who is working on the study, don’t discuss nutrition with pregnant clients beyond the standard talk about food safety and vitamin supplements. This even though the nutrition, as far as it goes, is pretty basic — stop drinking soda and juice, start eating vegetables and whole grains.

Today, says Stotland, America — even California — is a toxic food environment.

As cities go, San Francisco is svelte. In fact, according to statistics collected in 2008 by the Centers for Disease Control and Prevention, we would be the least chubby county in California if it weren’t for Marin. Despite this, Stotland says, every year a higher and higher number of her pregnant patients come in with preexisting diabetes and hypertension — even ones who don’t seem especially overweight.

A few generations ago, says Stotland, common folklore like “eating for two” while pregnant was probably sound advice. Before birth control, pregnancies were so closely spaced that women probably did need to increase their calories substantially when they became pregnant again. And most did manual labor — cultural standards for “rest” would have been different then.

Processed food existed, but it was in fairly short supply. Asian and Latino women are more likely to gain weight around their abdomen than women from other ethnic backgrounds, and so even if they don’t gain as much, they’re at a greater risk for diabetes and high cholesterol, which in turn makes them more vulnerable to C-sections, prolonged labor, preeclampsia and dangerously large babies.

But Stotland has another worry. These young women could have the health problems they do because they’re her first generation of patients born during California’s obesity epidemic. And now they’re having children themselves, and possibly extending the cycle of health risk into another generation.

At the same time, Stotland is hesitant. So often pediatric science can be an exercise in preemptively blaming mothers for everything. The occasional glass of wine while pregnant, for example, has gone from being standard practice to socially verboten in the United States, and while some research suggests it is reasonably safe after all, the American Congress of Obstetricians and Gynecologists maintains there is no safe level of alcohol  consumption during pregnancy.

In the meantime, Kim Coleman-Phox, project director for the stress-reduction study, thinks that much of the blame for the rise in obesity will be heaped on the ubiquity of high-fructose corn syrup, reasonably or not. “It’s in bread,” says Coleman-Phox, exasperated. “Why should bread have HFCS in it? It’s on its way to becoming the next red dye #2.” She thinks for a minute, then sighs, lightly. “It’s hard being a human.”