Wednesday, December 14, 2016

Nutritional Epigenetics and Prenatal Diets

Nutritional Epigenetics and Prenatal Diets: “I’ve been eating this way for years”

by Natali Valdez

Between 2012 and 2014 I completed participant observations and interviews at two clinical
trials, one in the United States and one in the United Kingdom. These trials tested nutritional
interventions on ethnically diverse pregnant women who were deemed obese. The recent trend to
test nutritional interventions on pregnant populations is related to the emergence of postgenomic
science. Scientists believe that a woman’s weight and diet during pregnancy can influence the
health risks of her developing fetus, and of future generations. Moreover, theories in nutritional
epigenetics claim that food can act as an environmental factor, which can modify genetic regulation
and expression. Therefore, the nutritional interventions targeting obese pregnant women are
intended to provide a healthy nutritional environment for the developing fetus.

In my ethnographic work at the clinical trials I found that food or nutrition came to mean
many different things to the scientists designing the intervention and the participants receiving the
intervention. For instance, based on the design manuals I read and interviews I had with the
principal investigators and collaborators at the StandUP trial, nutrition was framed through the notion of glycemic control. Glycemic control aims at minimizing foods that are high on the glycemic index. The glycemic index is a tool that categorizes foods based on how they will affect blood sugar levels. Therefore, the intervention focused on controlling or limiting foods that are high in sugar, saturated fats, and carbohydrates. At the trial the women in the experimental group would receive the nutritional intervention, which consisted of meeting with a health trainer at least eight times to learn how to change their diet through glycemic control.

The justification of the nutritional intervention based on glycemic control was explained to me in the following way: if a pregnant woman eats a donut, she will experience a spike in her blood
sugar levels, which will cause a cascade of reactions related to glucose metabolism. Eating a donut
will also expose the fetus to metabolic and hormonal reactions. In this case, the donut is an
environmental factor that stimulates metabolic and hormonal reactions that affect the fetus. In the
trials that I examined, pregnant women are not explicitly told that their diet is an environmental
factor. However, the scientists at the StandUP trial drew from nutritional epigenetics to justify the
significance of nutritional interventions during pregnancy precisely because food can act as an environmental factor. From my observations, the explicit framing of food as environment remained
in the realm of the scientists and not necessarily in common conversations among pregnant
participants in the trial.

From the perspective of pregnant participants enrolled in the experimental group, nutritional
epigenetics disappeared from view and what came into focus were the women’s cultural and
emotional entanglements with food. On a sunny afternoon in April Mary came in for her last
intervention visit with Diana, the health trainer for the StandUP trial. Mary was the first generation
born in England whose parents and family were all from Senegal. She self identified as African and
was studying for her masters in computer engineering in the UK. Diana identified as Afro-Caribbean since her parents migrated to England from Jamaica. Diana was one of the few women of color working on the StandUP trial.

During the session, Diana asked Mary, “what are the main staple foods in Senegal?” Mary
replied, rice, okra, and palm oil. Diana then reminded her that some of those foods were high on the
glycemic index. She then proposed that when Mary goes back to Senegal to visit her family, she
will need to focus on portion control. Mary responds, “portion, portion, portion, I do not want to
share a house with you [Diana], too much portion, I just put a plate of food down and as long as you
want to eat you just mix, eat, tummy is full.” Mary states this with a huge smile and both women
started laughing. The session continues and Diana walks Mary through a few different
questionnaires. Diana then asked Mary, “what’s been your biggest achievement and challenge?”

Mary responds by stating that her biggest achievement was how the intervention had “changed the
way I eat, the way I think about food – I behave myself more,” she says this again with a big cheeky
smile. To address the second part of the question, Mary goes on to say that one of her biggest challenges was having to always be “aware of everything, like portions and liquid beverages, I’m
not used to it, it will be hard because I’ve been eating this way for years.”

Although Diana and Mary have a warm jovial dynamic during the intervention delivery,
Mary was sincere in expressing how the intervention affected her. Take the example of portion
control. Controlling one’s portion was at first a foreign concept to Mary. The idea that one would
measure a “serving” of food calculated by grams of sugar, carbohydrates, and fat is a different
epistemological approach to food, eating, and sharing. As Mary mentioned here and in other conversations she usually just put a big plate of different kinds of food in the middle of the table and
everyone would take what they wanted. In this way encouraging the idea of portion control
intervenes not strictly in the nutritional aspect, but it also intervenes in a cultural and social way of
relating and sharing foods with others. Mary also recognizes that the intervention has “made her
behave more,” which indexes how the nutritional intervention intended to change her existing
eating habits. In addition, the idea that the intervention makes her “behave more” reflects the
underlying notion that prior to the intervention she was not “behaving” when it came to her food
and diet choices.

This snap shot of a nutritional intervention during pregnancy illustrates how different
approaches to food and nutrition are conceptualized at different levels and spaces within the same
clinical trial. On the one hand the scientific discourse and approach to the intervention focused on
nutrition as an environmental factor affecting fetal development, and glycemic control – a method
to intervene spikes in blood sugar levels. On the other hand nutrition or diet from the intervention
delivery was seen as a fundamental change in Mary’s life. A change in how she eats, shares, and
thinks about food. The juxtaposition of both these narratives exposes how a scientific tool like a
nutritional intervention is not a neutral object, but one that is rendered meaningful in different ways
based on how people engage with it.

Since returning from the field, it is clearer to me why a critical feminist perspective within
science studies and reproductive anthropology is fundamental in the examination of epigenetics.
Reproduction and pregnancy are at the center of epigenetic knowledge production, and as Rayna
Rapp reminds us, reproduction is also at the center of social theory. I appreciated the opportunity to
write this short reflection for CAR newsletter because it pushed me to think through material I have
not examined since completing the dissertation.

Natali Valdez completed her PhD in June 2016 in the Department of Anthropology at the University
of California, Irvine. She is currently a Postdoctoral Fellow in the Center for the Study of Women,
Gender, and Sexuality at Rice University. At Rice she will be working on her book manuscript titled
“Weighing the Future: An Ethnographic Examination of Epigenetics and Prenatal Interventions.”

Wednesday, August 3, 2016

UnBreaking Birth

I recently watched this video "UnBreaking Birth" - a lecture by Ryan McAllister. It is basically a version of the lecture I have given a couple of times as a guest lecturer undergraduate women's/sexual health classes.

"How you're born affects the rest of your life, and can affect the rest of your mother's life, too"

"There are a host of values at play beyond safety"

He says our birth care system is broken for at least 4 reasons:
  1. There isn't a sufficient amount of space and time to build an adequate relationship between the mother and the caregivers
  2. Our interventions have become routine, instead of based on the mom and baby's best interests
  3. Those interventions are often opinion-based
  4. There are conflicts of obligation within the hospital that systematically cause behavior that is out of alignment with the mom and baby's best needs

"Even when they know that practicing a different way would be better for their clients, they have some reason to practice differently. That means that there are conflicts of obligation in the hospital. At times, when the hospital's best interest is over here, and the patient's best interest would mean you behave this way, the hospital's best interest wins."

"Obstetrics has been organized around handling high-risk, emergency surgical births. and they may do this well. But treating all births this way actually derails well-birth, which is the vast majority of births. So I think we need to keep the good of this system and pair it with another approach that doesn't break well-birth."
"How could we possibly find or create highly trained experienced professionals who have evidence based practices, who work within a strong relationship wit h the mother, compassion for newborns, and don't experience conflicts of obligation with a large institution?... Those practitioners already exist. They are independent midwives."

The video does not have ALL of the information on the topic, but is a nice overview for consumers. It covers:
  • Why birth is broken (evidence that we spend more on maternity care in the U.S. but have worse outcomes; evidence that c-sections are too high and it is not caused by women being in worse health)
  • The 4 reasons he believes our maternity care system is broken 
  • A system that would work better for well-birth (certified professional midwives, birth centers)
  • What YOU can do to help improve the system
This would be a great video to share in a class, because it is only 32 minutes long.

"Being aware of and making available these other options, especially independent midwives, but also including other birth assistants such as doulas, is key to unbreaking birth in the U.S."

I like the way the UnBreaking Birth says about the indicators that we have a serious problem. It is basically a run-down of why I do what I do as a public health professional and a doula/childbirth educator:
  • there are terrible health disparities by race and socioeconomic status
  • infant and maternal mortality rates are higher than in 45 other nations
  • the maternal mortality rate has risen every year since 1995 while in most other countries it has decreased
  • only 25% of obstetric practice guidelines are based on good scientific evidence, many are overtly contra-indicated
  • common hospital policies are not in the best interest of moms and babies
  • and we spend more than any other nation on healthcare
  • Friday, July 29, 2016

    We Make Plans and Babies Don't Follow Them

    That moment when you're headed to your first doula prenatal visit with a first time mom who is 35 weeks, and she calls you and says "So, it has been an interesting day... My water broke and I'm being admitted. Do you want to make your way to the hospital instead of my house?"


    Luckily, despite our not having spent much time together, this mama was very calm and collected. And funny. I explained that she should do nipple stimulation to get contractions going (and avoid pitocin), I said "I know it feels weird to get sexy right now, but as they say, sometimes 'what gets baby in gets baby out'!" And she replied, "Maybe we shouldn't have had sex this morning!" And we both laughed.

    Did you know BabyCentre UK has a bunch of safe sex positions for pregnancy images? Now I do!

    I was nervous about a preterm baby, and any changes this might cause to the labor management plan, but everything turned out great. We did end up with pitocin to start contractions but mom labored with no pain meds and pushed her baby out in 6 quick hours.

    It was one of those labors where I left work, doula-ed all night, and then returned to work in the morning, with no one realizing that while they slept and went about their routine, I was having an extraordinary night!

    You learn something new every birth:

    • The doctor told the mom that she couldn't start with cervidil instead of pitocin because her membranes had ruptured. 
    • The nurse said the mom could use nitrous oxide during pushing if she wanted it (which she didn't). I've never seen it used during pushing. I feel like that would be hard to do both!
    • I've never heard a nurse so insistent on the use of drugs for stitch repair on a non-epidural mom. She said mom could use the nitrous during stitch repair, but she couldn't hold her baby. Mom declined. She then told her she could give her stadol in her IV, and didn't even tell her the pros and cons. I said "that will make her loopy, right?" the nurse finally said, "yes." Mom agreed and regretted her decision when she felt totally out of it and couldn't do anything about it for an hour. 
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