Discussions and Counseling About Obesity Should Begin in Adolescence

Washington, DC—Over the last three decades rates of obesity among adolescents in the United States have doubled, from 10 percent in the 1980s to 21 percent in 2014. In new guidance, out today, The American College of Obstetricians and Gynecologists (ACOG) emphasizes the need for ob-gyns to be aware of and sensitive to obesity in adolescent patients.

According to the new Committee Opinion, “Obesity in Adolescents,” adolescents affected by obesity face serious short-term and long-term physical and mental health complications that are often otherwise uncommon in their age group, including cardiovascular disease, diabetes, non-fatty alcoholic fatty liver disease and breathing complications. Obesity can also lead to specific gynecologic risks, from abnormal or heavy uterine bleeding to polycystic ovary syndrome; and for obese adolescents who become pregnant, greater risk of cesarean delivery, preeclampsia and gestational diabetes.

As the leading health care providers for women, ob-gyns are in a unique position to educate their adolescent patients about the risks of obesity. Ob-gyns also play an integral role in providing the appropriate counseling regarding behavior changes to improve an obese patient’s health.

“Ob-gyns should be a trusted resource for obese teens and their parents,” said Bliss Kaneshiro, MD, Committee Opinion author. “We have a responsibility to provide critical information about active lifestyles and healthy caloric intake, but we must also listen carefully to patients’ and their parents to ensure we’re addressing the health concerns thoughtfully and collaboratively.”

The new Committee Opinion, underscores that sensitivity is paramount to counseling and treating obesity in adolescents. Teenage girls face significant social stigma around their weight from peers, family, and the media that can lead to depression, anxiety, low self-esteem and in some instances, self-harm. Ob-gyns should screen for these factors, and be prepared to refer patients to school and community based resources, as well as psychiatric services. Without proper support, struggling with their mental health may limit obese adolescents social, educational and professional engagement, leading to fewer opportunities as they continue to grow-up.

Early intervention in obesity can have lasting positive effect. When adolescents received adequate support and treatment resulting in healthy weight loss, many of the health risks attendant to obesity and their long-term consequences are entirely mitigated.

In addition to counseling obese patients on healthy behavior changes, the Committee Opinion includes several key recommendations:

• Physicians should be knowledgeable about both behavioral and environmental factors that may influence obesity.
• Obesity can cause serious complications during pregnancy, and obese patients should be counseled about the benefits of hormonal contraception to prevent unintended pregnancy.
• Physicians should counsel overweight and obese adolescents against the use of weight loss supplements.
• A multi-disciplinary team, including a bariatric surgeon, dietitian, and psychologist or psychiatrist, should be used to identify appropriate candidates for surgical intervention and provide post-operative support.

Committee Opinion #714, “Obesity in Adolescents,” is available in the September issue of Obstetrics & Gynecology.

Other recommendations issued in the September issue of Obstetrics & Gynecology

Committee Opinion #715, “Social Etiquette for Program Directors and Faculty”

Educators in obstetrics and gynecology work within a changing clinical learning environment. Ethnic, cultural, and social diversity among colleagues and learners have increased, and methods of communication have expanded in ever more novel ways. Clerkship, residency, and fellowship directors, in partnership with chairs and senior faculty, are urged to take the lead in setting the tone for workplace etiquette, communication, and social behavior of faculty and trainees to promote a high standard of civility and citizenship. The Council on Resident Education in Obstetrics and Gynecology (CREOG) Education Committee has promulgated recommendations that can be used to help address professional relationships, professional appearance, and social media usage. These recommendations also address communications pertinent to educational processes such as interviewing, teaching, evaluation, and mentoring.

Committee Opinion #716, “The Role of the Obstetrician–Gynecologist in the Early Detection of Epithelial Ovarian Cancer in Women at Average Risk”

Ovarian cancer is the second most common type of female reproductive cancer, and more women die from ovarian cancer than from cervical cancer and uterine cancer combined. Currently, there is no strategy for early detection of ovarian cancer that reduces ovarian cancer mortality. Taking a detailed personal and family history for breast, gynecologic, and colon cancer facilitates categorizing women based on their risk (average risk or high risk) of developing epithelial ovarian cancer. Women with a strong family history of ovarian, breast, or colon cancer may have hereditary breast and ovarian cancer syndrome (BRCA mutation) or hereditary nonpolyposis colorectal cancer (Lynch syndrome), and these women are at increased risk of developing ovarian cancer. Women with these conditions should be referred for formal genetic counseling to better assess their cancer risk, including their risk of ovarian cancer. If appropriate, these women may be offered additional testing for early detection of ovarian cancer. The use of transvaginal ultrasonography and tumor markers (such as cancer antigen 125), alone or in combination, for the early detection of ovarian cancer in average-risk women have not been proved to reduce mortality, and harms exist from invasive diagnostic testing (eg, surgery) resulting from false-positive test results. The patient and her obstetrician–gynecologist should maintain an appropriate level of suspicion when potentially relevant signs and symptoms of ovarian cancer are present.

Committee Opinion #717, “Sulfonamides, Nitrofurantoin, and Risk of Birth Defects”

The evidence regarding an association between the nitrofuran and sulfonamide classes of antibiotics and birth defects is mixed. As with all patients, antibiotics should be prescribed for pregnant women only for appropriate indications and for the shortest effective duration. During the second and third trimesters, sulfonamides and nitrofurantoins may continue to be used as first-line agents for the treatment and prevention of urinary tract infections and other infections caused by susceptible organisms. Prescribing sulfonamides or nitrofurantoin in the first trimester is still considered appropriate when no other suitable alternative antibiotics are available. Pregnant women should not be denied appropriate treatment for infections because untreated infections can commonly lead to serious maternal and fetal complications.

Committee Opinion #718, “Update on Immunization and Pregnancy: Tetanus, Diphtheria, and Pertussis Vaccination”

The overwhelming majority of morbidity and mortality attributable to pertussis infection occurs in infants who are 3 months and younger. Infants do not begin their own vaccine series against pertussis until approximately 2 months of age. This leaves a window of significant vulnerability for newborns, many of whom contract serious pertussis infections from family members and caregivers, especially their mothers, or older siblings, or both. In 2013, the Advisory Committee on Immunization Practices published its updated recommendation that a dose of tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis (Tdap) should be administered during each pregnancy, irrespective of the prior history of receiving Tdap. The recommended timing for maternal Tdap vaccination is between 27 weeks and 36 weeks of gestation. To maximize the maternal antibody response and passive antibody transfer and levels in the newborn, vaccination as early as possible in the 27–36-weeks-ofgestation window is recommended. However, the Tdap vaccine may be safely given at any time during pregnancy if needed for wound management, pertussis outbreaks, or other extenuating circumstances. There is no evidence of adverse fetal effects from vaccinating pregnant women with an inactivated virus or bacterial vaccine or toxoid, and a growing body of robust data demonstrate safety of such use. Adolescent and adult family members and caregivers who previously have not received the Tdap vaccine and who have or anticipate having close contact with an infant younger than 12 months should receive a single dose of Tdap to protect against pertussis. Given the rapid evolution of data surrounding this topic, immunization guidelines are likely to change over time, and the American College of Obstetricians and Gynecologists will continue to issue updates accordingly.

Committee Opinion #719, “Multifetal Pregnancy Reduction”

Although not all multifetal pregnancies occur after the use of assisted reproductive technology, fertility treatments have contributed significantly to the increase in multifetal pregnancies. In almost all cases, it is preferable to avoid the risk of higher-order multifetal pregnancy by limiting the number of embryos to be transferred or by cancelling a gonadotropin cycle when the ovarian response suggests a high risk of a multifetal pregnancy. When multifetal pregnancies do occur, incorporating the ethical framework presented in this Committee Opinion will help obstetrician–gynecologists counsel and guide patients as they make decisions regarding continuing or reducing their multifetal pregnancies.

Committee Opinion #720, “Maternal–Fetal Surgery for Myelomeningocele”

Myelomeningocele, a severe form of spina bifida, occurs in approximately 1 in 3,000 live births in the United States. The extent of disability is generally related to the level of the myelomeningocele defect, with a higher upper level of lesion generally corresponding to greater deficits. Open maternal–fetal surgery for myelomeningocele repair is a major procedure for the woman and her affected fetus. Although there is demonstrated potential for fetal and pediatric benefit, there are significant maternal implications and complications that may occur acutely, postoperatively, for the duration of the pregnancy, and in subsequent pregnancies. Women with pregnancies complicated by fetal myelomeningocele who meet established criteria for in utero repair should be counseled in a nondirective fashion regarding all management options, including the possibility of open maternal–fetal surgery. Maternal–fetal surgery for myelomeningocele repair should be offered only to carefully selected patients at facilities with an appropriate level of personnel and resources.

Practice Bulletin #182, “Hereditary Breast and Ovarian Cancer Syndrome”

Hereditary breast and ovarian cancer syndrome is an inherited cancer-susceptibility syndrome characterized by multiple family members with breast cancer, ovarian cancer, or both. Based on the contemporary understanding of the origins and management of ovarian cancer and for simplicity in this document, ovarian cancer also refers to fallopian tube cancer and primary peritoneal cancer. Clinical genetic testing for gene mutations allows more precise identification of those women who are at an increased risk of inherited breast cancer and ovarian cancer. For these individuals, screening and prevention strategies can be instituted to reduce their risks. Obstetrician–gynecologists play an important role in the identification and management of women with hereditary breast and ovarian cancer syndrome. If an obstetrician–gynecologist or other gynecologic care provider does not have the necessary knowledge or expertise in cancer genetics to counsel a patient appropriately, referral to a genetic counselor, gynecologic or medical oncologist, or other genetics specialist should be considered. More genes are being discovered that impart varying risks of breast cancer, ovarian cancer, and other types of cancer, and new technologies are being developed for genetic testing. This Practice Bulletin focuses on the primary genetic mutations associated with hereditary breast and ovarian cancer syndrome, BRCA1 and BRCA2, but also will briefly discuss some of the other genes that have been implicated.

The American College of Obstetricians and Gynecologists (The College), a 501(c)(3) organization, is the nation’s leading group of physicians providing health care for women. As a private, voluntary, nonprofit membership organization of more than 58,000 members, The College strongly advocates for quality health care for women, maintains the highest standards of clinical practice and continuing education of its members, promotes patient education, and increases awareness among its members and the public of the changing issues facing women’s health care. The American Congress of Obstetricians and Gynecologists (ACOG), a 501(c)(6) organization, is its companion organization. www.acog.org