Increasing numbers of pregnant women in Norway are overweight. Heidi Sandsæter has studied what overweight and obese pregnant women perceive as the cause of this trend.

She is a midwife and has seen this development first hand. "Research in other countries has shown that there is a direct correlation between weight and a difficult childhood in some adults. We wanted to find out if this was also the case in wealthy Norway," Sandsæter says.

Sandsæter is a Ph.D. candidate at the Department of Public Health and Nursing at NTNU, and has used data from the Trøndelag Health Study (HUNT Study), published in PLOS ONE, to look at the connection between childhood experiences and weight before pregnancy. A total of 6,679 women participated in the study.

"Through the HUNT Study, the women have answered a simple question: On a scale of very good to very bad, how would they describe their childhood. We found that the higher the weight, the greater the chance of classifying their childhood as bad."

Not all overweight people have experienced difficulties in childhood, but this correlation is something that health care providers should bear in mind.

Sandsæter believes this shows that weight development isn't as simple as calories in and calories out.

"It is actually very complex, and we see that findings from abroad also apply in Norway. For health professionals, it is important to be aware of this. Not all overweight people have experienced difficulties in childhood, but it is something to bear in mind."

Unmet needs in childhood

In a follow-up study, published in Reproductive Health, the researchers wanted to hear the stories of the women behind the numbers. They interviewed 14 women who had recently been pregnant.

"We wanted to find out about their understanding of their own weight development up to the point they became mothers," says Sandsæter.

The 14 women came from different areas in Trøndelag County, were different ages and had different levels of education. What they had in common was that all had a body mass index (BMI) of over 30.

"The women had different stories to tell. Many blamed their weight gain on unmet essential needs during childhood. Some reported not having been given healthy and nutritious food so that their weight could develop normally, or that their needs for support and safe relationships were not met by their parents or peers," she said

In many cases, it was a combination of both.

"A common factor for those women who said they had felt insecurity was that they had experienced difficult relationships with their parents, or that they had experienced exclusion and bullying throughout much of their childhood," says Sandsæter.

The researchers identified four main themes in the women's stories. Unmet essential needs was one of them. Another was constant negative comments about their body and weight.

"We called this being 'under a critical eye,'" she said.

A struggle with food

The critical eye didn't just involve the direct or indirect attempts by parents to control their children's weight. It could also be the critical eye of their peers, or that as children or young people they noticed they were "different" from their peers and therefore became self-critical.

"Their parents may have meant well by watching how much their children ate during meals and constantly referring to their weight, but children quickly notice if something is wrong. They may perceive that their body is not good enough and therefore needs to be changed," says Sandsæter.

The researchers believe that having a negative perception of their own body may rob children of the ability to live their lives without constantly worrying.

"The follow-up that pregnant women receive during pregnancy has a health-promoting focus. It can be a golden opportunity to survey the causes behind pregnant women's weight development, and offer guidance on diet and health," she said.

"Constant criticism is not a good way to build self-esteem and a good body image. And having a good body image has been shown to inhibit the development of obesity," Sandsæter said.

A third theme has been called the "struggle with food" by the researchers.

"An interesting finding was that the participants who talked about unmet essential needs used food to regulate their emotions. Some developed a troubled relationship with food early on in their lives, while for others the difficulties developed in adulthood."

Those women who claimed they had a good childhood explained their weight gain by pointing more to other factors such as genetics or disease.

"This is also interesting. They don't blame themselves, like the women with bad childhood experiences do," says Sandsæter.

A golden opportunity

Sandsæter believes health professionals must overcome their reluctance to deal with topics such as overweight and obesity in pregnant women.

Overweight and obesity increase the risk of complications, during both pregnancy and childbirth. In particular, excess weight increases the risk of preeclampsia and gestational diabetes. Therefore, overweight women are advised to gain less weight during their pregnancy.

"The follow-up that pregnant women receive during pregnancy can have a health-promoting focus. It can be a golden opportunity to catalogue the causes behind pregnant women's weight development, and offer guidance on diet and health. In order to provide good guidance, we have to dare to ask why," says Sandsæter.

In this way, we can help reduce the risk, not only during pregnancy, but also for the mother and child in the future.

Sandsæter believes many people whose work involves prenatal care may find it difficult to talk to women with obesity about topics such as weight, health, diet and activity. She believes health professionals need to learn more about how to talk about weight and lifestyle in a non-judgmental and motivating way.

"You might be afraid of stigmatizing or offending someone, but our study shows that more women gained a more positive view of their own body during pregnancy. They were fascinated by what their bodies were capable of, and they felt fine when their baby bump started to show. As caregivers, we shouldn't represent the 'critical eye' that many feel they are subjected to, or be someone they feel they cannot trust. This is precisely what several of the participants have described as the origin of their obesity development," Sandsæter.