Thursday, June 10, 2010

Exaggerating the Risks Again

Here we go again. 

Yet another article has been published in the mainstream media (the New York Times, disseminated through its news service), hyperventilating about the risks of "obesity" in pregnancy.  And it includes the typical distortions, exaggerations, and apocryphal personal stories as part of  the usual tactics to scare fat women into either drastic measures to lose weight before pregnancy, into draconian interventions during pregnancy, or to scare them out of even contemplating pregnancy at all. 

We've covered this territory before, and I'm sure we'll cover it again in the future, but let's chat about why this is more scare tactics and marketing than anything else.  I don't have time right now to do a detailed smack-down of the numbers and studies but we'll talk about the main problems with the article.

Lack of Use of Real-Life Numbers

First, they need to stop discussing the risks of "obesity" in pregnancy exclusively by the means of odds ratios, which distort the sense of risk around an issue.  Include the real-life occurrence of such problems, so women of size can assess for themselves just how risky (or not) something is. That helps put the risk in better perspective.

For example, the article states that there is a higher rate of birth defects in "obese" women.  And it's true that some studies have suggested that there is 2-4x the risk for birth defects in obese women.  Sounds scary, doesn't it?

Yet rarely do the studies (and especially the press releases) mention that doubling a very small risk is still a very small risk.  Yes, the risk for Neural Tube Defects in "obese" women seems to be increased in some studies, but even so, the actual numerical risk is still likely less than 1%. 

That means that 99% of "obese" women will not have a baby with a Neural Tube Defect.  Do you come away from reading these stories feeling like the actual risk is that small?

Although odds ratios can be useful at times, be careful when articles don't also include the actual numerical occurrence. It's too easy to distort the sense of risk around something otherwise.

Distorted Risk Perspective

The article mentions prominently that "obese" women are more likely to have diabetes and high blood pressure complications.  This is true, and definitely a concern.  But the article fails to mention that most obese women will not experience these complications. 

For example, Weiss (AJOG, 2004), a large study of more than 16,000 women in multiple hospital centers, found that 9.5% of "morbidly obese" women (BMI more than 35) experienced Gestational Diabetes during their study.  The number certainly is higher than the 2.3% with a BMI less than 30, so it is definitely a risk (4x the risk---gasp!) that should be communicated to women of size. 

However, it also means that 90% of "morbidly obese" women did not develop Gestational Diabetes.  So while the risk increased, it should be remembered that the vast majority of morbidly obese women will not get GD. 

Pre-eclampsia is another risk that is substantially increased in "obese" women, and this one can be life-threatening to both mother and baby.  It is definitely a risk that must be discussed as a possibility and taken very seriously.  But in the Weiss study, only 6.3% of "morbidly obese" women developed Pre-eclampsia....higher than the 2.1% of non-obese women (3.3x the risk---gasp!) who developed PE, but hardly universal.  Remember, 93% of "morbidly obese" women did not develop Pre-eclampsia in that study. 

Again, the majority of these women did not get GD or PE, the two most common risks for women of size.

So while these risks are real and it's only sensible that the possibility be discussed with women of size (and that women of size be proactive about lessening their risk for them), it's important that the magnitude of the risks not be exaggerated or to imply that such a complication is virtually inevitable. 

[For the data wonks: Every study finds a somewhat different range of occurrence of these conditions, so you can definitely find studies out there that find both higher and lower rates of GD and PE than the Weiss study cited here.  However, many of these studies have significant weaknesses (too-small sample size, differing thresholds for defining various things, lack of recognition of the role that iatrogenic interventions may play) so each study must be vetted carefully.  The Weiss study is a multi-center study, has a very large sample size (16,000+ patients), and has information about a number of common risks, so it is a fairly robust study to use to look at the rates of these complications.]

Correlation Does Not Equal Causation

Another common mistake these articles make is to conflate correlation with causation.  The implication is that if anything goes wrong, obesity itself caused the problem, and therefore the solution is easy.....just lose weight beforehand.

But if being fat caused all these various complications, all fat women would get the complications, and they do not.  Furthermore, many women of average size get these complications too.  The picture is more complicated than simple cause-and-effect.

Another possible theory is that underlying metabolic differences is really behind these complications, and the fatness is merely a byproduct of these metabolic differences, a symptom if you will. 

Making the women diet will likely not help much unless the underlying metabolic differences are also addressed.  Trying to fix things by losing large amounts of weight is too simplistic an approach.

Furthermore, losing weight carries risks as well.  Women who lose a great deal of weight before pregnancy tend to have large weight gains during pregnancy as their body compensates, and that has its own risks.  Losing weight before pregnancy also puts the woman at risk for nutritional shortfalls, a big concern just when nutritional demands are about to be at their peak. 

A simplistic cause-and-effect view of obesity and complications can lead to many dubious conclusions and harmful therapies.  Yet researchers and authors continue to conflate correlation and causation in obesity research all the time.

Simplistic Approach

Another consistent problem with articles like these is their simplistic treatment of obesity and fat people's health habits.  But fatness is not a simple topic. All fat people are not alike and therefore one "fix" for them all is unlikely to work.  It may even harm. 

Some folks really are fat because they eat poorly and don't get enough exercise, and some folks really are fat because they have an eating disorder.  But research clearly shows that fatness also has a very strong genetic component.  Some people have underlying hormonal or metabolic disturbances (like PCOS) that create a propensity to being fat and great difficulty in losing weight.  Environmental factors (easy access to highly processed foods, less opportunities for exercise) plays a role for some people, yet many thinner people eat highly processed foods and get little exercise but are not fat.

There simply are no easy answers as to why some people are fat and some are not, but researchers and authors of articles like these want to pretend that there are because it makes them feel better.  They want to continue the simplistic mantra that fat people are fat simply because they eat terribly and get little exercise.  They want to believe that if everyone just ate right and exercised enough, everyone could be "normal" in size and therefore all complications from obesity could be avoided.  But this is not realistic and the abysmal long-term success rates of weight loss studies demonstrates this all too well.

Emphasizing health instead of weight may be a better approach, and might help prevent some of the complications, regardless of whether a person actually experiences weight loss.  For example, research shows that regular exercise can lower the rate of Gestational Diabetes in fat women.  It may or may not help them lose weight, but it can lower the rate of GD. 

And we must not forget that multiple weight loss attempts are often associated with greater weight gain in the long run Ironically, by emphasizing weight loss as the main "cure", doctors are likely recommending the one thing most likely to actually cause a worsening of fatness in the long run. 

Doctors and researchers want simplistic answers because then they can feel like they can "fix" things for women, but the answers are rarely that simple.  The best "fix" for obesity-associated concerns may be to emphasize health habits rather than weight loss.

Ignoring the Risks of Intervention

Doctors like to "do" things when presented with a possible risk, but they are slow to realize that sometimes the "doing things" does more harm than good or causes the very problem they are trying to prevent. 

For example, one of the things that really frustrated me when I read the article was the following:
Very obese women, or those with a B.M.I. of 35 or higher, are three to four times as likely to deliver their first baby by Caesarean section as first-time mothers of normal weight, according to a study by the Consortium on Safe Labor of the National Institutes of Health. 

While doctors are often on the defensive about whether Caesarean sections, which carry all the risks of surgery, are justified, Dr. Howard L. Minkoff...said doctors must weigh those concerns against the potential complications from vaginal delivery in obese women.
The implication here (and alas, many doctors share this perception) is that cesarean sections in women of size are safer than vaginal birth.  Barring major complications, nothing could be further from the truth. 

The truth is that cesarean sections are FAR more risky than vaginal birth for all women, and especially so for "obese" women.  There is the risk of anesthesia complications, hemorrhage, blood clots, and a very serious risk for infection.  Doing surgery on a very fat woman is complicated, and the relative lack of vascularity in adipose tissue means that oxygenation and therefore healing is more difficult. 

Yet despite the documented increased risk from cesareans to "obese" women, more and more doctors are doing them pre-emptorily.  They have such an exaggerated sense of risk around vaginal birth in women of size that they no longer are willing to let fat women even try.....or will only "let" them try if they induce labor early.  And therein lies the answer to much of the high cesarean rate in women of size.

Virtually every study shows an increased rate of inductions in women of size.  We know from other studies that high rates of induction often result in high rates of cesareans, but none of the studies on cesarean rates in obese women actually connect the dots and acknowledges that their excessive induction rates may be a primary cause of the high cesarean rates.  Nor does this article bother to mention this possibility. Instead it implies the obesity causes the cesareans. (Again we're back to correlation versus causation.)

If fat really prevented giving birth vaginally, it would have done so in the past too. But if you look at studies from the past, the cesarean rate in "obese" women was similar to that of average-sized women.  Obesity doesn't cause cesareans.  What has changed is the PERCEPTION of risk around women of size, and the MANAGEMENT of their pregnancies and labors, and that has resulted in higher cesarean rates. 

Being perceived as high-risk and treated as high-risk often creates a self-fulfilling prophecy. 

Doctors are so fearful about the hyperbole around obesity and pregnancy that they seek to control this sense of risk by overusing early inductions and planned cesareans, but there is no proof that this improves outcome.  Instead they merely expose women of size disproportionately to the substantial risks of surgery.

Using Worst-Case Scenarios To Scare Women

Another typical tactic in these stories is using a fat woman with a worst-case scenario story and implying that this experience is common. 

Ironically, the women in these stories typically aren't even very fat.  This illustrates the point they want to make of Just.How.Dangerous.Obesity.Must.Be because this terrible thing happened to a woman who was not even that fat!!  [Imagine the risks for a woman who was really fat!!!]

One of the first scary newspaper stories I read years ago about pregnancy and obesity used a moderately fat woman (less than 200 lbs.) as its bad-mother example. She developed pre-eclampsia, the placenta abrupted, and her baby died.  The article ended with the woman swearing to lose weight so that the same thing wouldn't happen next time. The implication was that if she developed pre-eclampsia and a stillbirth at her weight, all the bigger fatties out there had no hope. 

I remember the article because I'd just had my first baby. I was quite a bit heavier than she was and yet I hadn't developed pre-eclampsia, I didn't have an abruption, and my baby didn't die.  Either I was a walking miracle or the risk of pregnancy in someone my size might be more variable than they were implying. (I was just glad I had read the article after I'd had my baby, or I would have been they no doubt wanted me to be.)

In the New York Times article a woman named Patricia Garcia is used as the bad-example-du-jour.  She had a stroke during pregnancy, she developed pre-eclampsia, and her baby had to be delivered 11 weeks prematurely because its growth was not progressing properly. 

The study mentioned in passing that she had a "constellation of illnesses related to her weight, including diabetes and weak kidneys."  This makes it sound like her weight is to blame. 

But if so, why don't most fat women have diabetes and resulting kidney damage during their childbearing years?  Only a small percentage of fat women have pre-existing diabetes before pregnancy. And if this was caused by weight, why aren't we then seeing very high rates of strokes in "obese" women? I know of no study to quantify how many "obese" women have pre-existing diabetes, get pre-eclampsia, and then have a stroke, but the number is surely quite small, given the numbers in the Weiss study.  Yet this article makes it sound like it's a common occurrence.

Of course, the ironic thing is that she's not even very large to begin with.  Near delivery she was 261 pounds, but most of that was edema, a common byproduct of pre-eclampsia.  Before pregnancy she was only 195 pounds. I'm considerably larger than her; if weight causes diabetes, why didn't I have pre-existing diabetes plus kidney damage before pregnancy?

Rather than the problem being from her weight itself, likely there is something metabolic going on.  She mentions that she is the smallest one in her family; her brother weighed more than 700 lbs before having a gastric bypass.  To have a sibling be that supersized and to have yourself have diabetes badly enough to have developed significant kidney damage by age 38 means that something else is going on, likely something metabolic.  This is not just someone who "can't control themselves" but rather someone who likely has a lot of genetic and metabolic blocks stacked against her. It doesn't mean that all fat women of her size are facing a similar level of risk

My heart truly goes out to this woman and all she has been through.....but especially because of all the guilt they have laid on her about her weight "causing" this complication.  She has enough to deal with already.

Of course, the article ends with the mother pledging to lose weight and reform so she can see her baby graduate from college:
Voila.....bad mother becomes good mother by pledging to buckle under and toe the line. Cue the violins....even though there is no way to know whether going on a "strict, strict, strict diet" would have prevented this from happening, will prevent future complications, or will instead just result in yet another yo-yo that will end with her being fatter than she even started. 
I'm going on a strict, strict, strict diet," she said.  "I'm not going through this again.

It's not that we should never discuss worst-case scenarios; some fat women do experience major complications and their stories deserve to be told.  The problem is that the worst-case scenarios are presented in these articles as if they are a commonplace occurrence, as if that level of complication is common to most fat women......and it's not. 

And NONE of these articles ever tell the story of fat women who experience healthy, normal pregnancies, when that is actually a more common story. 

It's the lack of balance in these stories that is so bothersome.

Ulterior Motives

Underneath all of this lies the real purpose of the promote bariatric obstetrics. It's subtle, but if you read carefully there is hint of an underlying agenda in the article. 

Re-read the article again and notice how prominently the article emphasizes what a terrible burden obesity is on neighborhood hospitals, how they are having to buy all this specialized equipment for all these fat people, and how much Ms. Garcia's medical bills cost, etc. 

Then notice how it conveniently mentions that a bunch of hospitals in the NYC area are considering banding together to provide a specialized clinic for obese clients.  As the article says:
One possibility is to create specialized centers for obese women.  The centers would counsel them on nutrition and weight loss, and would be staffed to provide emergency Caesarean ssections and intensive care for newborns, said Dr. Adam P. Buckley, an obstetrician and patient safety expert at Beth Israel Hospital North who is leading the group. 
The idea of a centralized clinic to deal with the specialized needs of "obese" women is not a brand new one; several places around the country (and world) already do this.  But it is a trendy one, and one with powerful economic incentives.

The advantages of specialized centers is that only one place has to buy the specialized equipment that may be needed for supersized clients.....larger BP cuffs, longer anesthesia needles, sturdier tables, etc.  Since getting doctors and hospitals to supply and regularly use large BP cuffs etc. can be a problem, this might actually have some benefits.  But really, don't these hospitals also serve fat non-pregnant people?  Shouldn't they be stocking larger equipment anyhow?  Or are we going to start centralizing care for all fat people next?

The problem with the idea of centralized care is that it ghettoizes fat pregnant women, as we've discussed before.  It creates a climate rife for over-intervention, with little questioning about whether the interventions are prudent or even necessary.  It applies the "super high risk" label to all fat pregnant women, whether or not they actually experience complications, and subjects them to extreme amounts of intervention they may not need.

The induction and c-section rate in a bariatrics obstetrics specialty is likely to be even more astronomically high, because the doctors automatically see the obese woman as super high-risk.  And it's likely that the fat women at these centers will not be offered access to midwifery care, waterbirth, positioning options, or choices that can help lower the rate of sections and complications instead of adding to them. 

Historically, little good has come from classifying various pregnant populations as high-risk and treating them as such before any such complication occurs.  All that really happens is that more women undergo risky inductions and planned cesareans, and their infants experience higher levels of interventions that interfere with breastfeeding and bonding.  The high-risk label often leads to increased intervention without improvement in outcomes, and this is likely true also for women of size.

Furthermore, postpartum interventions will no doubt also include being bullied even more strongly than usual about nutrition and weight loss, and there will probably be a lot of gastric bypasses coming out of these programs, another financial boon for the hospitals.

Before such bariatric obstetrics centers are embraced across the country, they need to prove that their high-tech, high-intervention approach actually improves outcomes.  The cesarean rate should be lower in such bariatric centers, the fetal outcomes should be better, and they should have a high rate of long-term weight loss success.  But nowhere is there any research proving any such thing.  Instead these centers are allowed to open and operate without any closer review, and their intervention rates are allowed to go unchecked and unreviewed.

Another even more compelling issue is that the right to self-determination of care will be taken away from fat mothers if they are forced into these "obesity ghettos."  As long as the baby is healthy and there are no major complications, fat women should have the right to choose the style of care they want, the amount of intervention they prefer to use, and the way they want to give birth, just like any other woman does. 

If they want the high-risk ticket, they should be able to choose that.  But if they have little or no complications, are otherwise low-risk, and want alternative options like midwives or waterbirth, they should have the right to determine that for themselves, not be forced or scared into the Fat Farm Chophouse.

To paraphrase Susan Hodges of Citizens For Midwifery, "How much 'risk' does it take to supercede the mother's right to bodily integrity? Or self-determination?"

Apparently, all it takes is extra pounds.


It's not that the possible risks of "obesity" and pregnancy should never be discussed with women of size.  Of course they should.  Women deserve to be informed of the possible risks.

However, this article was full of distortions and worst-case scenarios, and it implied that experiences such as stroke during pregnancy are extremely common in fat women.

Anyone reading these types of articles might well conclude that virtually no fat woman has ever had a healthy pregnancy or a healthy baby, that the only way to have a healthy pregnancy is to lose vast quantities of weight first, and that the vast majority of fat women experience major complications and have unhealthy babies. And that simply doesn't jibe with the experiences of most fat mothers.

Yes, women of size are at increased risk of some complications. But the article distorts the magnitude of that risk and presents weight loss and highly interventive care as the only paths to a healthy pregnancy.

In fact, many women of size have healthy pregnancies and healthy can read many of these stories on my website.  I was one of them. I somehow managed to have four healthy babies at a much higher starting weight than the woman in the article. Despite being larger than her, I never had diabetes, I never had pre-eclampsia, I never had kidney problems, and I never had a stroke. And I know many more fat women just like me, in all sizes of fatness, who had healthy pregnancies and babies, in all sizes of fat. But THAT part of the obesity story doesn't get publicized.

It's not that you cannot discuss the possible risks of obesity in pregnancy with women. But it needs to be done in a fair and balanced way. This article was not well-balanced, it didn't discuss the possible risks in a reasoned and calm manner, nor did it acknolwedge that many women of size can have healthy pregnancies and babies.

Sensationalistic articles like this are done to shame and scare women out of pregnancy, or into compliance with draconian interventions like weight loss surgery, lack of weight gain during pregnancy, extreme prenatal testing, unnecessary inductions, or planned cesareans.  Postpartum, they try to shame women into emphasizing weight loss at any cost, despite the fact that long-term research shows that nearly all diets will fail, many of the women with weight loss surgery will experience nutritional complications, and that weight loss attempts are one of the major factors in weight gain over the long run. Approaches like this will likely just worsen the problem, not improve it.

Furthermore, while I'm sure some of these doctors have good intentions towards helping women of size, there is an undertone of economic incentives here that is being ignored. 

By exaggerating the risks of obesity in pregnancy, doctors, hospitals, and insurance companies can push for centralized services that cater primarily to "obese" women, and bill for more services and interventions because these women are "so high risk."  This"bariatric obstetrics" approach is a tremendous potential cash cow for providers, and it's no coincidence this article appeared in the Times just as the hospitals there are considering creating a centralized treatment clinic.  This article was not meant just to inform but also to market the new profitable field of bariatric obstetrics to other doctors and to obese women themselves.

Although there can be advantages to centralized facilities for women who experience major complications, fat women with healthy pregnancies should not be forced into these facilities to receive care. It is wrong to imply that all fat women are at the same level of risk as the woman in this story, or that we all require such specialized care. Many of us actually do better in low-tech, low-intervention care.

Yet more and more I am hearing from fat women who are being DENIED the opportunity for homebirth, birth center birth, or a VBAC trial of labor, simply because of weight, regardless of actual health or complications. I am hearing from women of size who are being REQUIRED to go to these bariatric obstetrics hospitals where they are not given access to midwives or low-tech/alternative options. Their rights and choices are being taken away from them, simply because they are fat and perceived as ultra high-risk.

Being fat does not mean your right to choose your own preferred style of care is forfeit. Right to bodily autonomy is everyone's right, regardless of fatness. But by exaggerating the risks of obesity and concentrating on the worst-case scenario stories, the authorities try to make a case for taking away just that.

No, we don't have to ignore potential risks, and information about proactive ways to lessen risk can be helpful.  But stop the hyperbole about risk, stop treating obesity so simplistically, stop using only worst-case scenario stories in these articles, and stop trying to create a new profit margin by ghettoizing fat women and exploiting them for profit.

P.S. I hope other fatosphere bloggers and birth bloggers will dissect the Times article and blog about its  weaknesses.  I should not be the only one blogging about this issue, and we need a greater chorus of voices protesting such articles out there.


JMT said...

Thank you so much for writing this. That article was so disturbing, especially the dramatic little f*ck-you at the end. :(

Margot said...

Thank you for writing at length about this article. I found it insulting and worrying. I saw it mentioned in a tweet from @mybestbirth and replied a few times denying it's reliability and engaged with one other woman, a childbirth educator out of CO, that agreed with me. I'm going to post about this on my blog and I'll probably be quite short about it, b/c you've said it best here.
I hate that they fear monger fat people into worrying themselves silly about complications and interventions.
I'm one of those people. And being 14 weeks pregnant, worrying about my weight and my blood pressure constantly can't be good. Even though I'm seeing a midwife, I'm still really concerned about being risked out of a homebirth, something I REALLY want. When in reality, I will likely be just fine if I keep eating right and exercising, but the constant worry can't be all that good either. :)
So, again, thank you. I needed this.

boots said...

I just wanted to tell you that as a fat woman who's trying to get pregnant, your blog has been such a help and a comfort to me. Without it, I would have let myself get pushed around and frightened by fatphobic REs and OB/GYNs, and now I know enough to stand up for myself.

Atchka said...

I'm glad you analyzed this article. I first read about it on MeMe Roth's blog and was curious how somebody like yourself would interpret the article.

The funny thing about MeMe's blog post is that she takes the part in the article where they say that Ms. Garcia's pregnancy cost $200,000 (and that a "normal" pregnancy costs $13,000), then conflates that to somehow be representative of obese pregnancies in general.

"Obese Pregnancy = $200,000.00
Normal Pregnancy = $13,000.00"

Um... that's not what the article said, MeMe.

Another thing I was wondering about is whether Ms. Garcia was receiving adequate prenatal care. Poverty and obesity are strongly correlated, as are poverty and poor health care options. The fact that this woman arrived at the hospital with such an extreme case of edema suggests that she didn't have a regular OB to consult with.

I also like how MeMe uses this article to declare Fat Acceptance and HAES DOA. I posted a civil response on her blog, but I don't think she's going to use it. :)


Amanda said...

Thanks for writing about this! I read the NYTimes article two days ago and it made my blood boil, so I was hoping for a take-down :) Nicely done!

Lindsay said...

The things you post in your blog drive me insane (in a good way!). I just had my second daughter last year and, being a fat girl, was hit with so many "you must have" diagnosis. I was tested for GB and my sugars were 142 (I think the cutoff was 140), in the last 3 wks of pregnancy so they wanted me to take insulin shots, diet AND C_sect. I chose to make my diet a little healthier and ta-da, sugars were under "control" in ONE day.
I was also told, at that appt, that I shouldnt ride my bike anymore (I might fall), even though I had been doing it since day one. I gained a total of 14lbs with my last preg and was healthier than I had been in a LONG time! The doc required SO many special tests and appts and procedures just because I am overweight.

The 2nd baby did have a heart defect, which caused her to be 11.5 at birth. I chose to have her naturally and it worked! (surprise, surprise)No one has EVER told me (or even hinted) that it was my weight that caused it. We have been thinking of having another kid and her heart docs give their blessings with no mention of me losing weight before I conceive.

I really, REALLY appreciate your blog and all the things you write about. I felt so ashamed as a large preg woman in the eyes of the ob's even though I have NO reason to be.


Anonymous said...

Thanks, I'm been waiting for you to write a bit on that article. Ugg, one FB friend posted that article and another lady commented that ---'fattness' must be the reason that the c-section rate and maternal deathrate is so high (for everyone) not the rate of interventions etc------ That just made me so angry that --* anyone *-- would simplify the entire maternal health systems current shorefalls as 'it must be the fat people messing everything up'.
You know that many people thought that after reading that article!!!
What an irresposible article NYT!

Lori said...

Thank you for this breakdown of the Times article. I wholeheartedly agree with you that women of size shouldn't be denied birthing choices based solely on size! There are increased risks that come with increased weight, as you rightly point out, and I do think obese women need to be accurately informed of those risks. This article does, unfortunately, skew the risks. Too bad, because it would be nice to see a fair treatment of this subject, considering the fact that the American populace is increasingly heavy.

With all due respect, I think where we will have to agree to disagree is on the genetics of fatness. While I absolutely agree there is a genetic *component* to weight, I reject the notion that genetics are destiny. Just as women with the BRCA1 or BRCA2 genes aren't necessarily doomed to a breast cancer diagnosis, people with "fat" genes are not destined for obesity. It represents an increased risk, not an inevitable occurence. (Anecdotally, I am living proof of that, as a person of normal weight with 2 morbidly obese parents.)

And since we can't control our genes (yet) for people who are genetically predisposed- to any health issue- the answer is to mitigate the genetic risk by addressing the factors we *do* have control over. That includes managing metabolic issues (for which obviously we need better diagnosis and treatment), as well as leading a healthy lifestyle of good nutrition and adequate exercise, not to mention moderation of alcohol and avoidance of nicotine and other drugs. Even doing that, we will all still be at different sizes/weights. But in doing that, as you say, we would truly be "healthy at any size."

Meghan said...

I sincerely hope that birth can be seen a physiological process and not a pathology. This is an issue for all child-bearing woman, though apparently all the more urgent for women of size. As a "normal sized" woman who has been put through the wringer of OBs and insurance, I cannot imagine throwing in more pre-conceived notions to work against.

There are many women working for healthier birth practices in America (and other industrialized countries). Someday pregnant women, all pregnant women, will be seen as people. Or else we will all be subject to surgical birth, and physiological birth will be forgotten. I hope when my daughter has children she will have better options than I have; of course, this is what all parents work towards.

I guess I am trying to say that many women empathize with each other on the topic of our lack of control over our bodies while pregnant. That I hope as we all work towards our individual goals we will improve the collective.

Mel said...

Thank you, thank you for writing about this. When I saw this article I immediately made the rounds of my favorite birth bloggers, but could find no one talking about it. I couldn't agree with you more. Thank you for clarifying the numbers game and calling them out on such a biased piece of writing. My best friend is considered obese: 5'3" and just under 200#. Her two pregnancies have been healthy and non-eventful, with borderline GD for one (easily controlled with monitoring her diet) and she has had two of the fastest, easiest deliveries I've heard of. I'm so grateful that her doctors didn't treat her as a bomb waiting to go off. I can't imagine what that experience would have been like for her at a specialty center at which her very existence would be treated as an unacceptable risk.

Mind you, the OB practice she saw harped on her weight all the time, but didn't make any particular attempt at helping her make better nutritional choices: since when should an overweight pregnant woman eschew a small glass of OJ a day in favor of diet pop? Have the real food, hon...not the chemical substitutes! Just balance out the glass of juice with an egg and a piece of whole wheat toast, eh? They steered her toward fake "diet" food rather than encouraging her to have a more varied and nutritional diet. So she ate diet food and the fast food she was craving. She was told to stay away from fruit. Sure, you have to watch how much and what kind of fruit you have for blood sugar concerns, but that doesn't make fruit bad for you! Not a word about white flours, processed food, etc. No encouragement or examples of what a healthy snack might look like. Just reduced calorie junk. Bah. Just a list of arbitrary "no's" without any real information to help her make good choices.

Amanda said...

Thank you so much for this post.

When I read that NYT article, it just didn't seem quite right to me. It seemed logical on the surface that larger people would have more complications, but the article also seemed kind of hysterical in a way that seemed unnecessary. The article definitely left me wondering how much of that increased Cesarean rate was justified.

I came here via the Unnecesarean, and I really appreciate your reasonable response to this article. It's so helpful to see the statistics and understand what's really going on! I am definitely bookmarking this post and keeping it handy in case any of my friends of size have kids.

Maryn said...

Over the very high number of pregnancies in this country, the change of something going wrong being less than 1% is still a very large number of pregnancies. It should not be overlooked that obesity does carry increased risks. It's negligent to overlook obesity *because* of it's increased risks. The focus on obesity is because it, unlike smoking or drinking, require specialized equipment and training that not all doctors and hospitals have. It's good to know this so that an obese woman an find a doctor and hospital, or even a midwife, able to handle her needs. Women who smoke and drink during pregnancy are also increasing the risks of something going wrong, and this shouldn't be overlooked either.

What is very bothersome in this article though is how interventions are used without any indication. Just because someone isn't in the optimal physical condition doing all the right things (prime body weight, not a drinker or smoker, regular exercise, perfect nutrition, plenty of rest, avoiding cold cuts, etc.) shouldn't been used an an indicator to automatically cut someone open. Vaginal deliveries have a very small risk, but a c-section carries risks too, and higher risk than a vaginal delivery. It's ironic that the way to prevent that small chance of a problem is to cause a problem by just cutting someone wide open.

I want to see numbers on how many obese women who have vaginal deliveries have complications versus how many obese women who have c-sections without attempting a vaginal deliveries first have complications.

NavelgazingMidwife said...

Just wanted to let you know I'm working on a blog-piece, too. It isn't a bashing of the article, so you all might bash me! But, I am writing what I know. And isn't that what blogging is about?

I look forward to sharing it. I'm writing as fast as I can!

Anonymous said...

I'm glad to see you tackle this issue head on. Some OBs talk such nonsense. For example, how can the same obese woman need a scheduled section due to obesity (she declined), and the next time around because her previous baby was an very fast vaginal birth? So, she needs a section because of the risk of birth complications, and she needs a section because the last baby just popped right out?

And about pre-eclampsia. I think the frequency of this condition in pregnant woman of all kinds is a disgrace, and a result of poor management of pregnancy. Dr. Tom Brewer was able to eliminate "metabolic toxemia of late pregnancy" from his patients through diet, and his idea of diet meant 100 grams of protein a day, and plenty of food, including so many servings of greens you might never want to see a spinach leaf again. He didn't tell his obese ladies (often obesity caused by being poor) to eat less. He told them how to eat well with foods they could afford. He expected them to gain during pregnancy, and eat enough to grow a baby, placenta, a big strong uterus, and an adequate blood supply. I wish he had spent more time doing research, and less with patients, because his legacy seems to be fading. Why can't the OBs distinguish between sudden water weight gain, which can presage pre-eclampsia, and a healthy weight gain that grows the baby and puts a little fat on the butt and thighs for famine insurance and breastfeeding?

Janeen said...

Mel, this is one reason why I have refused to see a dietitian. Personally, I wonder why it's even been brought up when I have yet to gain above my prepregnancy weight, my blood pressure is normal, and my glucose levels are normal. Oh, probably because I'm obese in general. Well, I've been there, done that with dietitians and the focus is almost ALWAYS fewer calories, less fat, smaller portions sizes. BUT, the food examples? White pasta, low fat and low sodium soups (ladened with MSG), other diet foods that tend to be pushed on the overweight as the right way to eat. Hmm. Interestingly enough, what you are not told is that much of this diet food is very likely laced with chemicals that make you MORE HUNGRY! So, you consume diet food which makes you more hungry and you consume more of it which then makes you gain is this good? Where is the emphasis on eating WHOLE, QUALITY food that is not made in a lab?! So, I have given up on dietitians and I'm just focusing on trying to get more fruits and veggies in my diet which (especially being 35 weeks pregnant) has a way of filling me up. I'm not trying to lose weight but just eat healthier in general. I do find it ironic though that going to the HOSPITAL cafeteria, I find some of the WORST food there and while I got a salad, the salad dressing (while low-fat) had HIGH FRUCTOSE CORN SYRUP! D'oh!

I've told my husband (he's skinny so he doesn't get it at all when it comes to how hard it is to deal when you're overweight/obese in this world) that in most cases, it really doesn't matter HOW you lose the weight, it's LOSING the weight that matters. I could lose weight by being on cocaine and that would be just fine, it's the fact that I would be at a socially acceptable weight that matters and HOW I got there does not (thus the reason that major surgery such as gastric bypass is pushed so much).

Whew! Went off on a soapbox there!

Willow said...

The article made me, in a word, ill. Thank you so much for deconstructing it so well-- I'm still ranting, spitting, and screaming about it!

Jackie Gehring said...

Thank you, thank you, thank you for this! That article really pissed me off, but I didn't know how to respond--you did an excellent job.

Bundy said...

Thank you for this critical, informed and most of all honest blog. It is not only fat women who are oppressed and receive poor medical treatment through the medicalisation of fatness. My wife is pregnant, and on meeting the midwife for the first time last week, their indepth, evidence-based, insightful health assessment (apparently to ascertain eating and exercise behaviour) consisted of the midwife and her student turning their heads to the side, looking my wife up and down and saying 'it doesn't look like that any problem'. In our obesity obsessed times, non-fatness apparently = health, non-fat people do not receive the medical treatment they deserve either.

Unknown said...

Very good analysis! I would like to point out that neural tube defects, the main birth defect increased in obese pregnancies, is easily prevented by prenatal vitamins. The conclusion is that obese women are less likely to get prenatal care, which is obviously linked to poverty and lack of health insurance. Poor and minority women get inadequate prenatal care and are also more likely to be obese.
Higher rates of neural tube efects in obese pregnancies is an indictment of the U.S. medical system, not a biological consequnce of extra fat tissue.

zjackson said...


I have an educational survey from a professor at NC State that is exploring pregnant women's perceptions of body image and health. Would you be willing to post the information on your blog? Thanks so much.

Well-Rounded Mama said...

Lori, I agree with you up to a point about genetics not being destiny. Even if you have "obesity" in your genetics it doesn't mean you just give up and not live a healthy life....of course not!

But the point is that even WITH living a healthy life and controlling the factors you have control over, genetics may still cause people to be fat anyhow, despite their best efforts.

You have two "morbidly obese" parents but you are of "normal" weight. Sources say that if a child has two morbidly obese parents, chances are 80% that the child will be too. So you are in the lucky 20% that isn't. But while some of that is hard work, some of it is also luck. Some people can do everything "right" and work really hard and still be fat because genetic factors ARE really strong. Adoption studies clearly show's NOT just about environment and how hard you work at it. Genetics ARE very relevant too.

Personally, the explanation I like best is that of Loos and Bouchard, Journal of Internal Medicine 2003. They concluded there were four levels of genetic determination of obesity....genetic obesity, strong genetic predisposition, slight genetic predisposition, and genetically resistant. So there IS interaction between environment and genetics, but how much each role plays varies from person to person.

When I look around at the size/wt of people around me, fat or thin or in between, this seems the most reflective of real-life.

But you are correct....if we work on our nutrition and exercise and be as (sanely) healthy as we can, that's the best approach. THEN we will be the healthiest we can be at whatever size we are.

Well-Rounded Mama said...

Paul, SOME neural tube defects can be prevented by folic acid, but not all can. It's not JUST a matter of addressing poverty or not taking your vitamins.

The picture is more complicated with obesity. The original 1996 research that showed a higher level of NTDs in fat women also showed that taking folic acid (400 mcg) did NOT lower that risk. It did in the non-obese women, but it did NOT in the obese women. They've also shown in other studies that it's not due to lower intake of folate foods in obese women either.

Many folks have speculated that a higher DOSE of folic acid might be needed in women of size and THAT might be preventive. I think that idea holds a lot of merit, personally, but at this point we have NO proof of it. The dose looked at in the research was 400 mcg; might a dose of 800 mcg or 1200 mcg have more effect? Do we simply need more? Or is there something else at work here?

Yes, socioeconomic level is quite likely relevant to some extent in this issue, but even when they control for that in the research, "obesity" remains a risk factor. So there is likely more going on there than just simply that.

What we need is more research, frankly. I have an upcoming post on this whole topic where I'll discuss it in more detail. It's a complicated topic and frankly, the research is far too simplistic on it so far for any real answers.

spaceranger said...

Thank you for doing what you do here. I'm newly pregnant, 5'7" tall and just shy of 200 pounds. Shortly after my first prenatal appointment I was recruited for study of new newly-pregnant well-rounded women (not the wording they used). I called to find out more about the study (hoping to find support in keeping my weight gain during pregnanct at a healthy level) and was told that if I joined the study, the goal would be for me to gain no more than 6 during my entire pregnancy--but more ideally I wouldn't gain any wieght at all during my pregnancy. I was kind of horrified. Then I second guessed myself and wondered if maybe gaining no wieght really was more healthy for my baby--so I went to PubMed and dug through some peer-reveiwed articles and then felt compeltely justified by my initial horror.

I didn't join the study.

I feel like I can breath more easily when I read your blog. Keep up the good work. I'll keep coming back for more.