Antibiotic Underdosing in "Obesity"

One of the most critical areas of research in improving treatment and outcomes for "obese" people is the issue of weight-based dosing. 

In many drugs, dosages have been determined based on the norm of average-sized people.  This means that people who are significantly under or over this "norm" may not be receiving the dosage most optimal for their size, with lean folk potentially being overtreated and fat folk likely being vastly undertreated. 

Underdosing is of particular concern for "obese" people because it may lead to subtherapeutic concentrations of drugs and deteriorating outcomes over time.

However, deciding on optimal drug dosages is not a simple task.  Concern for obtaining the most effective dose must be balanced against concern over toxicity from a too-large dose. 

In the past, doctors were understandably reluctant to prescribe a very large dose of various medications for people with larger bodyweights because they were concerned about the potential for massive toxicity. 

In fact, doctors sometimes intentionally reduced the dose because they were concerned about greater possible toxicity in "obese" people.

Now, however, there is emerging evidence that in many drugs, outcomes are improved with the larger doses and suboptimal with smaller doses. 

This is one of the most pressing issues in pharmocotherapy because extensive research is needed to determine optimal dosing and which drugs benefit most from weight-based dosing, but this research has been slow to happen.  And even when the research is there, some doctors have been slow to adopt new guidelines. 

Let's look at several critical areas in which underdosing is a major issue.  First up.....antibiotics.

Antibiotic Underdosing

Antibiotic underdosing in "obese" people may be one reason why fat people have poorer outcomes after surgery and/or infections.  Furthermore, underdosing may be a particularly serious problem in very fat people. 

Remember, when you are on antibiotics, you are cautioned to take the entire prescription, not to stop when you start feeling well.  If you stop too soon, the bug may still be there at low levels. Then, when the antibiotics are stopped, the bug may opportunistically spring back to life in a more severe or antibiotic-resistant form. 

A similar effect may happen when "obese" people are underdosed with antibiotics.  The bug may be only partially knocked out, return in time stronger than before, or worse, develop a resistance to the subtherapeutic-level antibiotic.

This may be one reason (among several) why infection is a particular problem for "obese" people after surgery....the antibiotic dosages given to them may not be strong enough. 

Of course, different drugs work by different mechanisms.  Therefore, not all drugs need weight-based dosing because of the unique way they work........but it's clear that some do, and that the importance of this factor is only now becoming more recognized in the medical field. 

For example, even recent research (see study abstracts below) shows that:

• Many "obese" people are still routinely underdosed with antibiotics, especially "morbidly" and "super-obese" people
• Revised guidelines for weight-based dosing are underutilized by healthcare professionals
• Far more research needs to be done into the most effective drug dosages for people of varying sizes, but particularly for very fat people

It's very disappointing that there isn't more definitive information on this topic in this day and age.  You would think that this would have been well-studied by now.....or that there would be a tremendous push for more research on this right now, given recent studies showing the problem. 

Yet there really doesn't seem to be a sense of urgency or priority on this in the research.  There are a number of studies noting the paucity of research on the topic and pointing out the need for more, but there are few studies actually conducting research into this important area. 

[Ironically, what studies there are often are on weight-loss surgery patients. We may finally be starting to get data on drug dosages for very fat people, if only because bariatric surgeons need to improve their surgery stats.]

At the very least, more doctors should be aware of what research and guidelines we do have for more effective dosing...but they apparently aren't because it doesn't seem to be affecting the way many of them prescribe (see vancomycin study below).

You have to wonder how many fat people have died or been gravely ill because their doctors didn't utilize the most effective dosage for them.

This is really a critical area for future research and education among health-care professionals. But until they start paying more attention to this issue, it's up to us, as fat consumers, to push for more action and to advocate strongly for ourselves if we get sick. 

Standardized Dosing

Another problem that commonly leads to chronic underdosing of "obese" people is standardized dosing, where little or no flexibility is offered to the doctors regarding dose size. 

Weight-based dosing is all well and good when it's easy to adjust dosages (as in IV antibiotic therapy in the hospital) but many commonly-prescribed antibiotics are only offered in a "one-size-fits-all" package.

For example, a few years ago, I developed a roaring secondary bacterial infection around a holiday and went to an emergent care center to get quick treatment for it.  They recognized I really needed antibiotics at that point.  I asked them about weight-based dosing, and the doctor admitted that weight-based dosing probably would be more beneficial for someone of my size.  However, he pointed out that he had no choice because the medication only came in one dosage.  It was that or nothing. 

I needed two rounds of antibiotics to beat that bug.  The first one started to knock it out, and then it came back a couple of weeks later, stronger than ever (at which point I started coughing up blood). I'm lucky the bug got wiped out by the second dose of antibiotics. If I had been older or more fragile, that bug might easily have gotten me because it was a really nasty one.

Was my delayed recovery because I was underdosed due to standardized dosing?  Hard to know for sure because I've not found a lot of dosing information about that particular antibiotic, but I suspect underdosing might well have played a role. And how even more undertreated might I have been had I been truly supersized?

Of course, sometimes standardized dosing is logical.  In an emergency, no one has time to stop and figure out weight-based dosing and dispense it.  In situations where time is of the essence (i.e. trauma surgery, emergent cesareans), having standardized doses available makes sense. 

But many surgeries are pre-planned and there is plenty of time to figure out the proper dosage of antibiotic to really lower the chances of wound infection.  Yet, hospital protocol or lack of knowledge/data about weight-based dosing often prevents its use even when time allows for it. 

So although I'm still learning about this topic (and welcome feedback from healthcare professionals who are well-versed in pharmocotherapy), I think it's important to:

• Start raising awareness among fat people to ask more questions from their healthcare providers about weight-based dosing and when it's needed
• Ask healthcare professionals to raise their awareness of the issue
• Start pressuring healthcare researchers to do further study of this important topic

If half of Americans are "overweight" or "obese," then prompt attention to this issue is quite pressing so that outcomes can be improved in this group.

This problem is also pressing to the general public because antibiotic resistance is on the rise. If subtherapeutic levels lead to more antibiotic resistance, then underdosing "obese" people may be adding to the critical public health issue of antibiotic resistance.

Therefore, finding out and promoting the proper dosages for people of size may benefit not only fat people, but society as a whole. 

Research on Antibiotic Underdosing

In the meantime, here are two recent study abstracts on the topic of antibiotic underdosing in "obese" people. I was particularly struck by the vancomycin study. 

Vancomycin is a very strong antibiotic, typically used for severe infections; in the past it was often a drug of last resort.  Therefore, proper dosing of it is critical, especially the initial dose to "knock out" the infection, and then therapeutic dosages to keep the infection down and out afterwards.

Yet in the study, only 1/3 of "obese" patients received an "adequate" initial dose of vancomycin.

If you look at the full text of the study (available here), you see that when they further examined dosage by class of obesity, NONE of the people with BMI greater than 40 received an adequate initial dosage.

Furthermore, less than 1% of the whole "obese" group received the recommended weight-based dose.

They concluded: 

Our results highlight the fact that obese patients may be routinely underdosed as a result of the widespread practice of prescribing fixed-dose vancomycin.

The authors also noted that another study has suggested that dosing intervals may need to be more frequent in the "obese" population in order to maintain minimum therapeutic levels, which is another intriguing consideration. 

Other studies have found that it's not only the dosage of antibiotics that counts, it's also the length of treatment.  "Morbidly obese" people may benefit from a longer course of antibiotics than is standard.

Furthermore, recent studies have found that in particularly infection-prone areas, application of additional topical antibiotics into the surgical incision area significantly reduces the rate of post-operative infection. 

So the the concept of antibiotic underdosing may not just be about how much antibiotics should be given to fat people, but also where they are given, how often they should be given, and for how long. 

I'd love to see more specific studies devoted to these questions.

Final Thoughts

If antibiotic underdosing is so common in people of size, is it any wonder that "obese" patients have poorer outcomes from infections and after surgery? 

Granted, many variables factor into why "obese" people respond less effectively to wounds and infections, and antibiotic underdosing is definitely not the only issue.  It's important to be fair about that.  It's not only about antibiotic dosing.

However, underdosing is quite likely a vastly underestimated reason for poorer outcomes, and one that should be relatively easy to fix, given more awareness of and research into the problem.  We can't do a lot about other factors that cause poorer outcomes and higher infection rates, but dosing is a relatively easy problem to fix.

Therefore, it seems extremely important to me to raise more awareness around this issue and start pressing for more and better research on the topic.


Here are the research abstracts.  (Obviously, highlights and emphasis are mine.)

Multicenter evaluation of vancomycin dosing: emphasis on obesity. Hall RG 2nd, Payne KD, Bain AM, Rahman AP, Nguyen ST, Eaton SA, Busti AJ, Vu SL, Bedimo R.  Am J Med. 2008 Jun;121(6):515-8.

Department of Pharmacy Practice, Texas Tech University Health Sciences Center, School of Pharmacy, Dallas, Texas, USA.

BACKGROUND: There is a paucity of data available regarding the dosing of antimicrobials in obesity. However, data are available demonstrating that vancomycin should be dosed on the basis of actual body weight.

METHODS: This study was conducted at 2 tertiary care medical centers that did not have pharmacy-guided vancomycin dosing programs or other institutional vancomycin dosing policies or protocols. Patients who received vancomycin between July 1, 2003, and June 30, 2006, were stratified by body mass index and randomly selected from the computer-generated queries. Patients greater or equal to 18 years of age with a creatinine clearance of at least 60 mL/min who received vancomycin for at least 36 hours were included.

RESULTS: Data were collected on a random sampling of 421 patients, stratified by body mass index, who met the inclusion criteria. Most patients in each body mass index category received a fixed dose of vancomycin 2 g daily divided into 2 doses (underweight 82%, normal weight 90%, overweight 86%, and obese 91%).

Adequate initial dosing (greater than or=10 mg/kg/dose) was achieved for 100% of underweight, 99% of normal weight, 93.9% of overweight, and 27.7% of obese patients (P less than .0001).

Ninety-seven percent of underweight, 46% of normal weight, 1% of overweight, and 0.6% of obese patients received greater than or =15 mg/kg/dose recommended by several Infectious Diseases Society of America guidelines.

Pharmacists also failed to correct inadequate dosing because only 3.3% of patients receiving less than 10 mg/kg/dose had their regimen changed in the first 24 hours of therapy.

CONCLUSION: In this multicenter pilot study, obese patients routinely received inadequate empiric vancomycin using a lenient assessment of dosing. Greater efforts should be undertaken to ensure patients receive weight-based dosing because inadequate dosing can lead to subtherapeutic concentrations and potentially worse clinical outcomes.

PMID: 18501233   Full text available here. 

Antimicrobial dosing considerations in obese adult patients. Pai MP, Bearden DT.  Pharmacotherapy. 2007 Aug;27(8):1081-91.

Division of Pharmacy Practice, College of Pharmacy, University of New Mexico, Albuquerque, New Mexico, USA.

As obesity continues to increase in prevalence throughout the world, it becomes important to explore the effects that obesity has on antimicrobial disposition. Physiologic changes in obesity can alter both the volume of distribution and clearance of many commonly used antimicrobials. These changes often present challenges such as estimation of creatinine clearance to predict drug clearance.

Although these physiologic changes are increasingly being characterized, few studies assessing alterations in tissue drug distribution and the effects of obesity on antimicrobial pharmacokinetics have been published. The available data are most plentiful for antibiotics that historically have included clinical therapeutic drug monitoring.

These data suggest that dosing of vancomycin and aminoglycosides be based on total body weight and adjusted body weight, respectively. Obese patients may require larger doses of beta-lactams to achieve similar concentrations as those of patients who are not obese. Fluoroquinolone pharmacokinetics are variably altered by obesity, which prevents a uniform approach. Data on the pharmacokinetics of drugs that have activity against gram-positive organisms-quinupristin-dalfopristin, linezolid, and daptomycin-reveal that they are altered in the presence of obesity, but more data are needed to solidify dosing recommendations. Limited data are available on nonantibacterials.

An understanding of the physiologic changes in obesity and the available literature on specific antibiotics is valuable in providing a framework for rational selection of dosages in this increasingly common population of obese patients.

PMID: 17655508

Lazy, Slothful, and Indolent

This study sounds like good source material for those in the fat studies field. 

'Lazy, slothful and indolent': medical and social perceptions of obesity in Europe to the eighteenth century.

Sawbridge DT, Fitzgerald R. Vesalius. 2009 Dec;15(2):59-70.

University of Edinburgh.

Abstract

There is a considerable stigma associated with obesity, among healthcare professionals as well as the general population, which often leads to discrimination and weight bias. But why is there a stigma attached to obesity?

The origin of this stigma has been identified in the 18th century but its roots lie much further back in history. There is some debate about how this negative perception of obesity arose and the role of medical professionals in its creation. This paper examines both positive and negative conceptions by following three major aspects of the modern stigma through from Palaeolithic statues to the medical texts of ancient Greece and Rome, finishing with the medical and literary sources of the 18th century 'Enlightenment'.

The modern perception of obesity originated in the social and scientific climate of the Enlightenment through the combination of three key themes;

• obesity as conspicuous consumption,
• associations with suspect morals and excess, and
• as an outward representation of the soul

The evolution of each of these themes can be clearly identfied in pre-Enlightenment sources. By the eighteenth century, these perceptions became amplified by, and disseminated through, the literary and media boom to create a recognisably modern stigma against the obese.

PMID: 20527324

*Think about the typical "obese" characters on TV or in books, movies, and plays.  Most of them pretty much fit into "obesity as conspicuous consumption," "associations with suspect morals and excess," or "outward representation of the soul," don't they?

Which characters can you think of that fit these stereotypes? 

The one that springs immediately to my mind is the Baron in the Sting movie version of "Dune."  I think he fits all three of those.  Fat Hate Bingo!

Anyone else care to play?

Please Document Your Stories of Mistreatment

For years, I've made it a practice to document stories of fat-phobic treatment and weight bias in fertility, pregnancy, birth, and parenting. 

I do this for several reasons.

First, I find that many health practitioners simply aren't aware of (or don't believe) the extent of discrimination that exists out there towards women of size. Documenting actual stories helps them gain a better understanding of what some women of size have been through and why many are hesitant or negative about seeing a care provider. It also helps hold up a mirror (to medical professionals in general and to maternity providers in particular) to their own attitudes and practices, and helps them understand how bias -- even unconscious bias -- can slip through and how it impacts women.

Second, I think it's important that these experiences be documented simply because all stories of discrimination and bias deserve to be acknowledged.  Fat women should not have to endure egregious treatment like this, and our experiences of discrimination and bias should be heard and honored.  For too long, we've been told that such treatment is our own damn fault, that we're "too sensitive" about these things, or that we shouldn't be questioning it --- it's for our own good because we're so incredibly high-risk.  Documenting these stories makes connections with the discrimination suffered by other groups, shows that discriminatory practices have patterns, and that weight bias is a real form of stigmatization and discrimination.

Finally, I think it's especially important to document stories like this so that the fat-acceptance movement and the birth world start to understand and grapple better with the problem of fat-phobic treatment and discrimination during pregnancy and birth, an issue they tend to ignore.  Surprisingly, over the years I've found more respect and attention to the issue of size discrimination in the birth world than I have in the fat-acceptance world, which I always find puzzling and frustrating. Much of the birth world has a long ways to go, but some segments of the fat-acceptance world (those who don't want/have children, or are young enough that it's not on their radar) have an even longer way to go.  Documenting how egregious the treatment can be in pregnancy and birth is important because it helps establish that there really is a problem here that deserves attention, regardless of whether size discrimination affects you personally and regardless of whether you have (or plan to have) children or not.

More Stories of Mistreatment

A few weeks ago, I re-posted an entry from My OB Said WHAT?!! about a fat woman being told that if she got pregnant, she'd get gestational diabetes, high blood pressure, and would probably "die anyway."  This is just one of several "gems" I've found like that on that site.

I was surprised to get a high number of comments from my readers relating similar discriminatory stories, stories I'd not heard before and didn't have documented. 

While I'm disappointed that these things are still happening in obstetrics and midwifery care even today, I'm glad to be able to document some more of these stories.

But I want readers to go further.  If you have a story like this, I want you to document it thoroughly, in multiple places. 

We must have a record of things like this happening if we ever want to see things change.

How and Where To Document Your Story

So how do you go about documenting your stories? 

First of all, you can always send them to me, at kmom AT plus-size-pregnancy DOT  org.  I like to keep a record of such stories; when sending your story, please give me your permission to use them as needed (i.e. on my blog, on my website, in presentations I make, etc.).  You don't have to use your own name; you can choose to be as anonymous as you wish.  Just remember to give explicit permission to use it.  [If you posted your story in a public forum like my comments section, I consider that explicit permission...you've already made it public.  But I still like to have formal permissions.]

Second, don't forget the blogs at:

• First Do No Harm, http://fathealth.wordpress.com/
• My OB Said What?!?, http://myobsaidwhat.com/

The First Do No Harm site documents stories of discrimination against fat people in the healthcare world, but sadly, they have very few entries under pregnancy, reflecting the lack of crossover between the birth world and the fat-acceptance world, I think. The stories here on my blog need to get repeated there. 

The My OB Said What?!? site documents stories of outrageous treatment in the birth world; it's not just limited to fat folk, of course, but it's important that the birth world hear of size discrimination and weight bias and how prevalent it is.  And it's important that they hear about these stories from someone other than just me as well.  I am one of the very few voices out there talking about this; it would be great to have other voices corroborating the stories of weight bias and discrimination out there.

So if you have a story of bias or mistreatment, I urge you to submit your story and document it in multiple places.  There really is a lack of understanding and acknowledgement in both the birth and fat-acceptance worlds that such discrimination really exists and is so common, so be sure to document it in multiple places. 

Documenting our stories is one way to start raising awareness about this problem and start confronting and challenging such treatment.  We don't have to suffer in silence anymore, and by speaking up, we can start changing the status quo.

Here are just a few of the stories from the comments section of my last post, edited for length.  I thank these women for sharing, and highlight a few of their stories here because not everyone reads the comments and might have missed some of these.  [A few have beeen edited or broken into more than one story for the sake of readability.]

• My last OB told me that I needed to lose 50 lbs during my pregnancy or else she was sure I'd need a c section and then a hysterectomy. I gained 4 lbs total, and my baby was 8lbs 6 oz. I will never see that doctor again. I refused to go to my 6 week check up because of some of the nonsense that went on during my labor/delivery.

• I was told during my second pregnancy (I was about 6 weeks in) that I would have to have a c-section because I am fat. No ifs or buts, I simply would have to. I ended up having a straightforward natural (2 hour) labour and delivery and without any mention of a c-section.

• I was told at the beginning of my pregnancy not to gain any weight AT ALL. And in fact to lose weight. When I asked why, he told me because otherwise, I was being selfish and putting my baby at risk. Thing is, I was stuck with him because I had no insurance at the time and the delivery (emergency c-section that I HAD to have) still gives me nightmares.

• That I must have so much fat inside my vagina that I would not be able to give birth without forceps or more drastic interventions....That my blood pressure would shoot up in the midst of labor (despite having been perfectly normal all through my pregnancy) and I would die without IV drugs. Now, with my kids around me and the bed they were born in just a few steps away, I can laugh about it. Then, not so much.

• My MIDWIFE told me that she couldn't feel my baby through all of my fat. Which is funny, because she would barely touch me. Her doppler couldn't find the heart rate because I was too fat too. Once she dropped me from her care, I interviewed several other midwives, all of which could feel the baby AND find the heartbeat.

• I was mostly able to avoid the scare tactics, thankfully, but during my cesarean, after my husband left with the baby, someone said "We should just do some liposuction while we're in here."

• In my first pregnancy, at 11 wks I started spotting heavily, and my GP sent me for an u/s to see what was happening. I ended up in the imaging department at our local hospital with a sonographer who was visibly put out with having to take care of me. At one point she told me to 'hold all that fat out of the way' so she could do her job, and how she wasn't sure she would be able to 'see anything through all the fat'. Not only was I beyond stressed over the possibilitiy of losing that pregnancy (which I did, sadly), but that 'professional' made me feel awful.

• I was a virgin at my second gynecological exam requesting birth control for the first time and the doctor told me I needed to lose weight if I ever wanted to get pregnant. She said she would not "let me" get pregnant at my weight and that it would be too difficult for me to carry a child at my weight. I changed doctors when I found out I was pregnant a year later while on the Progestin-only birth control pill she prescribed me (I did research and that pill has a way lower rate of working on bigger women... - she never mentioned that). I was actually in fear that she would suggest an abortion or something drastic because she was so adamant that I not get pregnant at my weight. I think she thought I wasn't going to be having sex anyway at my weight or something like that. I weighed about 290. I am now 38 weeks pregnant at 305 pounds and the baby and I are doing great. No GD, no high blood pressure. We've been fine. Looking forward to a healthy baby later this month.

• I've got a ton of horror stories. I moved to the SF Bay Area from Seattle when I was 28 weeks pregnant and spent hours on the phone looking for a doctor that wouldn't counsel immediate termination ("You or the baby will die, you are just too fat to carry to term."), "necessary" c-section ("Women of your size never have a natural labor. You will have to have a c-section.") or were anti-VBAC ...("Women with your BMI can't VBAC in our hospital. You won't find a better hospital in the area."). I wound up with a doctor that said she was comfortable VBACing who decided at 38 weeks that I needed an "emergency" c-section and called me in the middle of my grocery shopping about me "dying before the weekend was out" and generally pressured me into yet another c-section. Now I'm being told (by any doctor I can find) that a VBA2C is "impossible" at my size/BMI or at all.

• I was told by my OB at the first office visit (8 weeks) that I needed to lose 15-20 lbs. When I asked if this would be harmful to the baby, I was told that I could safely LOSE weight during pregnancy and it would have no effect on my baby because I had so much "reserves" the baby could survive from that. Luckily I knew that was BS and ate normally to sustain my energy, stamina, and that of my baby. When he balked about my weight at every subsequent visit, I flat out told him that I KNOW how unstable I feel during dieting, and there's nothing he could say to convince me that would be healthy for my baby, he shut up.
  

• On the day of induced delivery, my doctor (who had been cautioning me that I would "most likely" need a C-section because of my size) was afraid to break my water as I neared full dilation and effacement and called in the OB specialist again to perform the procedure. My doctor actually left the room during this procedure to scrub in and ensure there was an operating room available to do an emergency C-section. When the specialist was finished and labor progressed normally, my doctor was shocked. Within three hours, my 9lbs 1oz baby girl was born and proceeded to pee all over the doctor. Instant Karma.....gotta love it.

• I am pregnant with identical twin girls. I went to the perinatologist and he lectured me for 20 minutes. Telling me I was going to have GD and high blood pressure, and that I needed to lose 20 pounds during this pregnancy.

• I had an OB tell me (over the phone) that I wasn't "really" pregnant, since my BMI was too high for me to actually be pregnant. Her office then told me that they'd be happy to schedule me for a biopsy to determine what kind of tumor I had. I replied "The kind with two arms, two legs and a head." and hung up. (I was 28-ish weeks pregnant and had a number of ultrasounds under my belt.)

You can read more stories of size discrimination I've documented over the years here.  There are stories of fat women being pressured to abort --- simply because of their size.  There are stories of women being told that they will die if they dare to be pregnant at their size.  There are stories of women pushed to have cesareans they don't need (or intervened right into cesareans). There are stories of draconian diets and mega-interventions and abusive treatment, simply because of weight. 

Of course, not every woman of size encounters such egregious treatment.  Oftentimes the bias is more subtle than that, and sometimes arrives with completely good intentions from the provider....but it's still bias.  I encourage you to share those stories too. 

It's also important to note that some fat women DO receive truly size-friendly treatment during their pregnancies and births; if you are a woman of size already pregnant or just considering pregnancy, please don't despair.  It IS possible to get decent treatment, and of course not all OBs or midwives are horrible people or size bigots.

But size discrimination does occur and I believe it's becoming more and more common as the rhetoric in the "War on Obesity" heats up. So it's important to keep documenting and challenging these incidents, both subtle and overt, as often as possible.

Please, folks, take time to document your stories, in as many places as possible.

Health care professionals and the general public need to become more aware of the scope of the problem of size discrimination.  It's the first step towards change.

"The Solution Needs to be Complex"

"The solution needs to be complex." Obese adults' attitudes about the effectiveness of individual and population based interventions for obesity.

Thomas SL, Lewis S, Hyde J, Castle D, Komesaroff P. BMC Public Health. 2010 Jul 15;10:420.

Consumer Health Research Group (CHaRGe), Primary Care Research Unit, Monash University, Melbourne, Australia.

Abstract

ABSTRACT: BACKGROUND: Previous studies of public perceptions of obesity interventions have been quantitative and based on general population surveys. This study aims to explore the opinions and attitudes of obese individuals towards population and individual interventions for obesity in Australia.

METHODS: Qualitative methods using in-depth semi-structured telephone interviews with a community sample of obese adults (Body Mass Index greater than or =30). Theoretical, purposive and strategic recruitment techniques were used to ensure a broad sample of obese individuals with different types of experiences with their obesity.

Participants were asked about their attitudes towards three population based interventions (regulation, media campaigns, and public health initiatives) and three individual interventions (tailored fitness programs, commercial dieting, and gastric banding surgery), and the effectiveness of these interventions.

RESULTS: One hundred and forty two individuals (19-75 years) were interviewed.

Participants strongly supported non-commercial interventions that were focused on encouraging individuals to make healthy lifestyle changes (regulation, physical activity programs, and public health initiatives).

There was less support for interventions perceived to be invasive or high risk (gastric band surgery), stigmatising (media campaigns), or commercially motivated and promoting weight loss techniques (commercial diets and gastric banding surgery).

CONCLUSION: Obese adults support non-commercial, non-stigmatising interventions which are designed to improve lifestyles, rather than promote weight loss.

PMID: 20633250

Weight Bias Among Dietetics Students

Puhl R, Wharton C, Heuer C. Weight bias among dietetics students: implications for treatment practices. J Am Diet Assoc. 2009 Mar;109(3):438-44.

Rudd Center for Food Policy and Obesity, Yale University, 309 Edwards, New Haven, CT 06520, USA.

Abstract

BACKGROUND: Several studies have examined attitudes about obesity among food and nutrition professionals, yielding mixed results, and no experimental research has tested the impact of dietitians' attitudes on their treatment practices or health evaluations with obese patients.

OBJECTIVE: This study investigated attitudes of dietetics students toward obese persons and tested whether a patient's body weight influences students' treatment decisions and health evaluations within a randomized experiment.

DESIGN: Between the months of September and December 2007, a convenience sample of 182 dietetics undergraduate students (92% women; mean age 23.1+/-5.4 years) from colleges throughout the United States completed online self-report surveys to assess weight bias (using the Fat Phobia Scale). Participants were also randomly assigned to read one of four mock health profiles of patients who varied only by weight-related characteristics (eg, obese or average weight) and sex (male or female), and asked to make judgments about the patient's health status and participation in treatment.

STATISTICAL ANALYSES PERFORMED: To compare group data, multiple analysis of variance was used to test for an effect of the patient's body mass index on participants' health evaluations and their perceptions of patients in each of the four experimental conditions. Correlations were calculated between mean fat phobia scores and perceptions of patients.

RESULTS: Participants in all conditions expressed a moderate amount of fat phobia (mean=3.7), and students rated obese patients as being less likely to comply with treatment recommendations compared with nonobese patients (P less than 0.05).

Results from multivariate analysis of variance tests showed students also evaluated obese patients' diet quality and health status to be poorer than nonobese patients, despite equivalent nutritional and health information across weight categories for each sex in patient profiles.

In contrast, obese and nonobese patients were rated to be similarly motivated, receptive, and successful in treatment.

CONCLUSION: Implications of these findings for education and intervention in dietetics training are discussed, with emphasis on increasing awareness of weight bias in existing dietetics curricula.

PMID: 19248859

*Comments?  Personal experiences with fat-phobic dieticians? Or size-friendly dieticians?

Is Weighing Necessary During Pregnancy?

A while ago, we discussed whether routine weighing at medical appointments is really necessary. 

I reminded people that if weighing bothers them, is triggering to them, or is just against their principles, then routine weighing can be opted out of because you have the right to informed refusal of any test or procedure.  I also reminded people of the times when weighing can be medically necessary versus when it's simply a matter of routine policy, and that the two should be differentiated.

But what about weighing during pregnancy?  Is it really necessary to weigh a pregnant woman at each visit?

Unfortunately, this question is not as simple to answer.  You can make a case both for and against routine weighing at every prenatal appointment.

For the most part, though, the question is moot, because most care providers require weighing at each appointment. You can question its necessity all you want, but most providers are going to require it.

If you are a woman of size who wants to bear children but prefers not to be weighed, the sad truth is that you are either going to have to:

• find a way to make peace with the weighing requirement, or
• be prepared to go outside traditional attendants to find those who are more flexible about routine weighings

Weighing = Standard of Care?

Among OBs in the USA, prenatal weighing at every appointment is considered standard-of-care.  If an OB were to not weigh a woman regularly and she later had a problem and sued, that OB could have his/her feet held to the fire in court for not weighing her. 

So, beneficial or not, for most care providers, the "standard of care" argument trumps all the other arguments against routine weighings.  It is simply what is expected medically and legally.

However, it's not "standard of care" in all countries to weigh.  Some doctors in other countries do not weigh pregnant patients at all, even fat ones. Others do not weigh average-sized patients, but will weigh patients regularly who weigh outside the "norm" --- that is, very thin or very fat patients. 

Midwives vary more in whether or not they weigh clients.  Many midwives (especially the ones in hospitals who practice with OB colleagues) do weigh women regularly, but not all do.  I have heard from several hospital midwives in other countries who do not regularly weigh their clients, and I have heard from others that do.  Much depends on the standard of care in that area, and whether or not the midwife practices within the medical model or not. 

Many homebirth midwives here in the USA and abroad do weigh patients routinely, but will let you opt out of it if you prefer.  I found a midwife like this for my fourth pregnancy. (Bless her heart forever). 

But basically, in the U.S., unless you are interested in the homebirth route and have a very flexible midwife, you are almost surely going to be weighed at each prenatal appointment. 

So what are the pros and cons of weighing pregnant women?  Why do it or not do it?

Arguments For and Against Weighing During Pregnancy

There are a variety of reasons providers give for weighing during pregnancy.  Some of them are very legitimate concerns, and some are more dubious.

Monitoring Pregnancy Weight Gain

The reason most commonly given for weighing routinely in pregnancy (and the reason I find least compelling) is to be sure patients don't gain outside the weight gain recommendations.

The main problem with this is that what is considered the "proper" weight gain in pregnancy changes over time. In the 50s, 60s, and 70s, women were told to strictly limit weight gain, to the point that many babies were being born underweight or premature. So then the weight gain guidelines changed, encouraging more weight gain to try and lessen these complications (which they did).

Recently, the more generous weight gain guidelines have been challenged, with many researchers contending that women gain too much weight now, putting themselves at increased risk for a "too-big" baby, a higher rate of cesareans, or retaining too much of the weight after the pregnancy is over. 

Both of these arguments have data to back them up. There is some research that suggests that really large gains are harmful in pregnancy, resulting in extra-big babies and more long-term obesity in the mother.  And there is definitely research that shows that a too-small gain is associated with prematurity and/or too-small babies, even in "obese" women. 

So obviously, a happy medium is the ideal.  But what is considered the "optimal weight gain" is still under debate.  Currently, the latest recommendations from the Institute of Medicine (IOM) are: 25-35 lbs. for "normal" weight women, 28-40 lbs. for "underweight" women, 15-25 lbs. for "overweight" women, and 11-20 lbs. for "obese" women. 

So while what is considered the "correct" weight gain is trendy and changes over time, you could certainly make a case that preventing the extremes of weight gain (too low or too high) might prevent complications, or catch them early enough to intercede. 

On the other hand, weight gain doesn't give much reliable information about a woman's actual nutrition or general health.  Some women have a gain within "normal" limits, yet do so eating mostly junk food.  Some women gain "too much," yet have perfectly good nutrition.  Weight gain as a proxy for a woman's nutritional intake and health is a shaky concept at best.

Furthermore, weight gain doesn't correlate all that well with outcome either.  Some women gain a large amount in pregnancy, yet have perfectly healthy babies and great outcomes.  Some gain less than optimally, yet the outcomes are still good.  Some women gain within the guidelines and have poor outcomes. Pinning too much importance on weight gain amounts is not a reliable indicator of outcome.

Personally, I think far too much importance is placed on the numbers on the scale instead of on the actual nutrition and habits of the woman.  The medical community relies on weight gain as a marker for appropriate nutrition and predictor of outcome, and I think these associations are weak at best. 

However, given the very short appointments most OBs have with patients and the difficulty this can lead to in knowing how a woman is eating, I can understand them wanting some way to monitor the pregnancy's progress.  Not all women are truthful about their nutrition to their providers, and a too-high gain or a too-small gain could be an early warning of someone who is having difficulties managing their food intake.  It could be a marker for the need to intercede early, so I can understand a provider's wish to weigh patients on that level.

Still, isn't the better option the midwifery model of care, which takes more time in each appointment so the care provider knows the client better and understands her particular needs and concerns? 

The midwifery model is the one that takes the time to really emphasize proactive care (including good nutrition) in preventing many complications. It takes time to thoroughly go over general nutritional principles in pregnancy, and it tailors nutritional advice to each woman's individual needs.

While some midwives do weigh their clients routinely to watch for any alarming trends, most de-emphasize the scale in favor of emphasizing the importance of excellent, proactive nutrition and exercise.  To me, emphasizing nutrition seems far more important to me than how much weight a woman actually gains (or not) in pregnancy. 

Most of the time, routine weighings to monitor weight gain as a surrogate for monitoring nutrition or predicting outcome is a weak argument at best, and  besides, judgments of the what is the "proper" amount of weight gain tend to change over time. 

In my opinion, a better approach is to emphasize excellent nutrition and regular exercise and trust the woman's body to gain the amount it needs.

Monitoring Fetal Growth

Another reason many  providers like to weigh women regularly in pregnancy is to monitor fetal growth closely.  As noted, research shows a too-large gain may predict a big baby, and a too-small gain may predict a premature or underweight baby, both of which are associated with risks.

Really large gains can be associated with macrosomia (big baby), and this raises the specter of shoulder dystocia (where the shoulders get stuck).  Although most of the time this is resolved without problems, sometimes this can cause damage to the baby, to the mother, or in rare cases, result in the death of the baby. It is one common reason for lawsuits in obstetrics, which is why doctors worry about it so much.

However, weight gain is only moderately associated with macrsomia. Many women gain average amounts in pregnancy and yet still have "big" babies.  Some people gain a lot in pregnancy and have average-sized babies. Some of us (me!) gain almost nothing in pregnancy and still have big babies.

I am dubious of the idea that weight gain is a really reliable marker for discovering macrosomic babies.  I think research does show that a really high gain increases the number of macrosomic babies but taking a large gain as a guarantee of a big baby amd acting in fear accordingly may cause more problems than it solves.

In fact, monitoring weight gain can backfire because a large gain often triggers an early induction or a planned cesarean for a "big" baby, only some of whom will actually be big, and many of whom will have poorer outcomes because of the interventions.

Research clearly shows that these interventions do not improve outcome and often worsen it, regardless of the size of the baby.....so monitoring weight gain closely and planning interventions based on large gains may actually cause more harm than good in many cases.

On the other hand, weight gain can be a good marker for small-for-gestational-age (SGA) babies.  Research consistently shows that poor weight gain in pregnancy is associated with SGA and/or premature babies.  A very low rate of weight gain, especially in a woman who is already on the thin side, is a marker for strong concern and could be considered a good reason to weigh pregnant women regularly.

However, in "obese" women, the relationship between weight gain and fetal size is more tenuous. Many of us do not gain much weight at all in pregnancy (or even lose a little) and yet still have babies of average or large size.

Yet it's important to remember that even in "obese" women, there is a relationship between low weight gain and SGA/premature babies. It's not as strong a relationship as in smaller women, but it is there.  This is one of the reasons why the push for very little or no weight gain in "obese" women is troubling.

So you could make a case that a woman of size who is not gaining much should have fetal size monitored, just in case.  Chances are that everything is fine in a woman of size with low gain, but it might be helpful to check baby's growth curve periodically, since SGA babies tend to be at higher risk for stillbirth and prematurity.

However, weight is not the only way to monitor fetal growth; measuring the height of the top of the uterus (fundal height) is pretty universal among care providers.  If a problem is suspected via fundal height, then more close supervision of the mother's weight gain might be appropriate, along with other measures of fetal growth. 

Estimating fetal size by ultrasound is also an option.  It's not that accurate at predicting a too-big or too-small baby, but it does fairly well in identifying babies that are average-for-gestational-age.  In other words, it has difficulty accurately identifying all the babies at the extremes of growth, but it's better at ruling out extremes of growth for many babies and reassure everyone that all is well.  This is not a perfect solution, but it is another option.

The argument for weighing women to monitor fetal growth is one that has some merit, but it also carries risks as well as benefits.  If a large gain is used as a marker for more intervention, chances are the risks will outweigh the benefits.  However, if it is used selectively, and particularly to watch for women with too-small babies, the benefits may outweigh the risks.

Pre-Eclampsia

Another major reason for weighing in pregnancy is that a sudden large gain can be a potential symptom of Pre-Eclampsia (PE). In PE, fluid retention is common, and one of the first clues to PE can be a sudden jump in weight gain.

Because PE is a very serious complication of pregnancy and a potential killer, this is one logical reason for monitoring weight gain closely in pregnancy.

The problem with this is that women don't gain weight uniformly each week in pregnancy. Some weeks there are bigger gains, some weeks there is very little gain. Unless there's a huge jump, a bigger gain one week does not necessarily indicate pre-eclampsia.

Yet most doctors measure gains on a diagonal line of "average" gain per week, and some overreact to any deviation from this average...especially in women of size. Realistic providers understand that gain is not always even week to week, yet it's unfortunately very common for women to be hassled about even a small gain above the average "permissable" gain.

While a really big, sudden weight gain jump can be used as a marker to indicate possible PE, even a small gain is often over-reacted to in women of size. Many providers believe that all fat women will develop PE, so they are quick to react to any gain above what they think "should" be taking place. Combine that with the lack of consistency about using a larger blood-pressure cuff in women of size, and many providers are quick to diagnose PE in fat women when there may or may not actually be a problem.

Routine weighing can be advantageous in that it may be one of the first signs that PE is developing, but it also often results in major interventions and hassles, particularly for women of size.

Iatrogenic Harms

What many providers fail to realize is that while regular weighings in pregnancy can sometimes spot complications early on and prevent them from becoming worse, they can also result in unneeded intervention and harm.

In many providers' eyes, a woman with a large prenatal weight gain is a cesarean waiting to happen. They assume that a large gain means a big baby, and so they are more likely to induce labor, do a planned cesarean before labor, or have a very low threshold for proceeding to a cesarean during labor because they are afraid of shoulder dystocia.

In fact research shows that a larger weight gain is associated with a higher risk for cesarean, even when the baby is not big.  Is this because something physical about the bigger weight gain prevents vaginal birth, or is it more about the provider's fear levels and anticipation of trouble?  I think there is a strong case to be made for the latter.

This is one of the problems with monitoring a pregnant women's weight gain closely.  Too often, it's not just neutral information, designed to prevent complications, but instead becomes loaded information used against the woman to instigate interventions at the slightest provocation. 

Are the majority of interventions used around weight gain monitoring really justified?  Do they truly improve outcomes?  Or do many of the interventions put into effect when a woman has a gain outside the norm cause more harm than good?

This is the question that researchers are not examining closely enough.  The medical model is good at helping the small amount of women who truly need assistance during pregnancy, but it is typically very poor at recognizing and changing its own physician-caused (iatrogenic) harms. 

And monitoring weight gain so closely that the care provider freaks out over every little ounce is a very common iatrogenic harm these days.

What If You Prefer Not To Be Weighed In Pregnancy?

Weighing women in pregnancy at every visit is the standard of care in the U.S.A. and in many other countries as well.  Even those places that don't weigh most women may want to weigh women of size regularly in the belief that this might prevent complications (or catch them early). 

Therefore, if you are a person who finds weighing triggering or have a strong philosophical objection to weighing, it can be difficult to find a birth attendant who will honor that objection.

Women of size who wish to avoid regular weighings should look into an alternative-style birth attendant, like a homebirth midwife or a birth center midwife. Although most of these care providers also weigh regularly, they are less likely to be adamant about it and may be willing to work out a compromise position.

Make questions about regular weighings part of your interview process when trying to find a provider.  Share honestly with them the reasons that you prefer not to weigh, and ask them frankly whether or not they could be comfortable avoiding the scale.  Offer to weigh yourself each week and keep track of your own gain, and to let them know if you see a big jump in gain or loss at any point, or if your gain is too low or extremely high overall.  

Reassure them that you care very much about your nutrition, offer to keep food diaries to reassure them that you are getting good nutrition, and note that you will be open to nutrition counseling as needed if it's non-judgmental and reasonable.

Some midwives who normally weigh will be comfortable with avoiding weighing under these conditions.  They just need reassurance that they will be told if there are any disturbing trends in weight gain, and that your nutrition will be consistently good. 

Some midwives will never be comfortable omitting weight gain in prenatal appointments, and in that situation you will have to decide just how important it is to you (or not) to avoid prenatal weighings.

Handling Weighings If Your Care Provider Insists On Them

If you have chosen a high-tech birth attendant who insists on weigh-ins and it bothers you to be weighed, you do have some options. 

Many women find it easier to endure weighings if they take control of the process themselves.  Some choose to turn their backs while being weighed.  Others request that the med tech weigh them without comment and write down the numbers without saying them out loud.

You can share your concerns about regular weighings with the care provider and ask them to let you have some control over the process, or at least to be careful about the kind of comments they make to you about weight gain.

At no time should you ever put up with shaming body talk or critical comments about your results.  Providers who indulge in that kind of talk will not be size-friendly during the birth process and are likely to see you as a disaster waiting to happen.  If you hear negative or shaming comments when weighing or about your weight gain, it's time to find a new provider.

Or you can do what I do when there is a medically-necessary weighing; I don't passively let someone else weigh me, but instead I tell them I can do it myself and they can watch to verify it. I move the scale to about the right number (so there's no long process of over- or under-estimating and adjusting), and I adjust the balance until it's correct.  Somehow it's not so bad or quite so threatening if I do it for myself. 

Sometimes I get a med tech who is very threatened by the idea of me weighing myself (I think they assume I must be trying to fudge the number), but most of the time they are fine with watching me do it.

Mind you, I still hate being weighed by strangers....it reminds me of all those diet program weigh-ins, all the judgment that went with those, and all the living and dying emotionally based on what the scale was doing...but I find it less offensive if I am the one in control of the process. And I never let them make comments about the results.

This was how I handled being weighed in my first 3 pregnancies.  Although I refuse routine weighings when not pregnant, I didn't realize there was any choice when pregnant and so I went along with the weighings the first 3 times.  It wasn't too bad.

Since I'm okay with what I weigh, check myself regularly at home, and don't have an eating disorder (some people with eating disorderes find weighing to be a trigger), I could make peace with the idea of weighing in order to rule out pre-elcampsia or a too-small baby.....but I can't say I ever enjoyed the process.  I just gritted my teeth and got through it. 

Best by far, though, was finding providers who did not require that I be weighed during pregnancy. In my fourth pregnancy, I found birth attendants who were okay with me opting out of weighing. They knew me well enough to realize that they could trust my nutrition and they knew I kept track of my own weight and would report any big gains or losses, and any pre-eclampsia symptoms.

So they were completely fine with me not weighing at ALL in the whole pregnancy, and I have to say, that was SOOOO incredibly freeing! What a breath of fresh air.

They may never realize what a gift they gave me by letting me opt out of that, but blessings on them forever for being flexible that way.

Conclusion

Weighing during pregnancy has many pros and cons. 

On the plus side, it can catch some cases of inadequate weight gain that may lead to a higher risk for a premature or too-small baby, or it may catch an incipient case of pre-eclampsia before it gets too serious.  A too-large gain, caught early, may allow intervention to improve nutrition and perhaps prevent some cases of macrosomia. 

On the minus side, weight gain measurement is often used against women (and especially women of size), leading to more interventions and risky procedures like inductions and cesareans.  Furthermore, it is a poor surrogate for predicting nutritional adequacy or pregnancy outcome. 

A more sensible approach would be to emphasize nutrition over weight gain.  Alas, in today's short appointments, meaningful nutritional counseling is difficult to do and weight gain becomes the stand-in measurement of nutritional adequacy. 

Therefore, to most U.S. maternity care providers, weighing during pregnancy is an absolute requirement. If you have decided to go with a typical OB or hospital midwifery practice, you will almost surely be weighed at every appointment. Find a way to deal with that process proactively so it's not bothersome to you. 

Beware the care provider who is highly restrictive, shaming, or overly-interventive based on your weigh-in results.  That is a classic sign of weight bias and will likely lead to a highly-interventive and high-risk birth.  Better to switch providers than have to put up with that kind of bias during pregnancy.

And if you really object to being weighed during pregnancy, remember that there are some birth attendants who do not require regular weigh-ins. If it's something that really bothers you, you might want to check out one of these providers and see just how freeing it can be.

*I'm interested in hearing YOUR experiences, in or outside the U.S.A.  Where are you from? Do care providers usually weigh women in pregnancy in your area?  Why or why not?  Do they weigh women of size more?  Do they recommend restrictive policies or use shaming comments? Do you think weighing was helpful or hurtful in your case?  How did you feel about being weighed?

If you are a provider, I'm interested in hearing about your reasons for weighing or not weighing, how you monitor nutritional adequacy, and if you weigh, how you help women through an experience many women (of all sizes!) find nerve-wracking. 

Putting Healthcare Practitioners On A Diet

Cotugna N, Mallick A. "Following a calorie-restricted diet may help in reducing healthcare students' fat-phobia." J Community Health. 2010 Jun;35(3):321-4.

Department of Health, Nutrition & Exercise Sciences, University of Delaware, 301C Willard Hall, Newark, DE 19716, USA.

Abstract

Data from National Health and Nutrition Examination Survey 2005/2006 show that 32.7% of US adults are overweight (BMI 25.0-29.9), 34.3% are obese (BMI 30-39.9), and 5.9% are extremely obese (BMI >or= 40). For the first time, the number of obese American adults is greater than those who are merely overweight. Negative attitudes and fat phobia toward the overweight exist not only in the general population, but also among health professionals including dietitians and dietetics students.

The purpose of this study was to determine if fat phobia might be reduced among future professionals by putting students on a calorie-restricted diet for a short period.

Forty dietetics and health promotion students enrolled in a university obesity course completed the Fat Phobia Scale test before and after following a calorie restricted diet for 1 week (1,200 calories and 1,500 calories for women and men, respectively). Students also reflected their thoughts about following such a diet via brief journal entries.

Results showed the change in fat phobias after following a calorie-restricted diet was significant. Many journal entries reflected a newfound respect for individuals struggling to lose weight and change in prior negative attitudes. Students reported that this experience would impact their future dealings with overweight/obese clients.

It may be useful to incorporate this type of activity into the training of nutrition and other health professional students to increase sensitivity and reduce existing biases and negative attitudes toward overweight/obese clients.

PMID: 20130971


**Personally, I think the dietetics students in the abstract above should have had to follow the 1200/1500 K diet for a lot longer than a week to see how it REALLY feels. A week is nothing; it's the long-term regimen that really takes its toll.

I don't have the citation for it anymore, but long ago I remember reading a study where diabetes education specialists were required to exactly follow a diabetes self-care regimen, including eating restrictions, self-measuring blood sugar 3-4x per day, completing exercise requirements, and to mimic taking medications on schedule.

They failed miserably.  It was a good lesson in patient compliance.  They gained new perspective into how demanding such self-care regimens can be, why patients don't always adhere 100% to them, and obtained new empathy for the stress of dealing with chronic healthcare concerns.

Comments?

Breastfeeding in Women of Size: Sensationalism vs. Meaningful Research

This post is in honor of World Breastfeeding Week. 

Mom's Tinfoil Hat did a post a while ago, talking about the recent study (and accompanying press release) that "obese" women breastfeed less.  She had a number of criticisms of it, as do I.

The medical community and their media lackeys love to do these "fat women breastfeed less" studies, but it really bothers me that they don't go beyond the sensationalist headlines when doing them.

I believe it is probably true that, when looking at women of size as a demographic group, they probably do breastfeed somewhat less than women of average size, and that documenting this is not necessarily a bad thing if it leads to meaningful research into the cause and more outreach to increase breastfeeding in women of size.

But when do they examine WHY fat women breastfeed less, other than to simply blame obesity? Where's the meaningful information that helps with the problem instead of merely reporting one?

Instead, they always go for the simplistic angle (Fat is bad!  Fat inhibits breastfeeding!) instead of trying to draw more meaningful information out of the issue. And frankly, I loathe the way they market these studies to the media, exploiting them to fan the obesity hysteridemic and to be as sensationalistic as possible.

Do they really think that story is going to be helpful to most fat women? Do you think most fat women who read that story come away thinking, "Yeah, I'd better get to La Leche League or a lactation consultant so I have the support I need for breastfeeding"?

Or do some fat moms read that story and think, "Oh well, I don't have a very good chance of breastfeeding, so what's the point?"

And what about healthcare professionals?  Do researchers really think most are going to read this and think about all the ways they can encourage women of size to breastfeed?  Some will, but many will not. Some are just going to conclude that it's probably hopeless anyhow, that this is yet another way in which fat women's bodies "don't work right" so why bother referring them to a lactation consultant or to La Leche League?

Although the researchers tell themselves that they are helping, I think the overall effect of such stories is to discourage breastfeeding among many women of size, not to encourage them to ask for help.   And while the article authors may sincerely feel they are "just trying to help," I think the end result is that publicity such as this makes the problem worse. 

It certainly encourages the perception that most fat women "can't" or "won't" breastfeed, when in fact most can and do breastfeed. The rates are lower than women of average size, yes, but there are significant numbers of fat women who do breastfeed successfully.  Where are the stories featuring these women?

And where is the thoughtful analysis of why the breastfeeding rates in women of size might be lower?  Why not study why fat women initiate breastfeeding less, and why they stop sooner?  Why not investigate more closely possible physiological reasons for milk supply issues? And why not study the differences between the fat women who do manage to breastfeed successfully and those who do not?

I think the reason is because most researchers aren't willing to ask the hard questions.  They want a quick and easy publishing score in a publish-or-perish academic world, they want simplistic answers ("See, fat interferes with lactation!  Therefore lose weight to fix the problem!"), and they are in denial about how their own practices lower the breastfeeding rate in women of size.

Many Factors Affect Breastfeeding in Women of Size

Many factors affect breastfeeding rates in women of size; the culprit may not simply be "obesity" itself, yet researchers always assume that it is.  In fact, as with so many issues, the association between "obesity" and lower breastfeeding rates may simply be due to correlation, not causation.

Here are some possible other factors that could explain why women of size have lower rates of breastfeeding. 

Management of Labor and Birth

As we recently discussed and Mom's Tinfoil Hat pointed out, many of these studies don't control for cesarean delivery, which research shows can impact breastfeeding initiation rates in particular, and to a lesser extent, breastfeeding duration rates too.  It can lessen the amount of milk a newborn receives, which may lead some women to give up breastfeeding or supplement excessively. 

Since the rate of cesareans in women of size is so high, this is likely a significant factor in why many fat women do not initiate breastfeeding or give up within the first few weeks. Not the only factor, but a significant one.

And labor management can torpedo breastfeeding as well. There's a terrific book called Impact of Birthing Practices on Breastfeeding: Protecting the Mother and Baby Continuum (by Mary Kroeger with Linda J. Smith) that documents how labor management affects breastfeeding. 

Many of the pharmacological drugs used in labor (artificial oxytocin, epidurals, IV narcotics) tend to lower the levels of hormones (like prolactin and endogenous oxytocin), inhibit milk secretion or suckling behaviors, or have lower breastfeeding rates associated with them.

The high rate of interventions commonly used in the births of "obese" women often leads to a "perfect storm" of conditions that interfere with breastfeeding. [See my experience below.]

Yet even otherwise comprehensive reviews of breastfeeding and obesity often fail to mention how high-intervention labor management may affect breastfeeding initiation and duration in women of size. 

This is part of the determined blinders that obstetric caregivers put on about how rates of undesirable outcomes (high cesarean rates, low breastfeeding rates) can be iatrogenic.....that is, influenced by caregiver management practices. 

Understandably, no care provider wants to believe that they are negatively affecting outcomes in their patients, but any worthwhile study of medical interventions must take account the possibility of unexpected negative side effects from these interventions.   

While labor interventions are clearly needed sometimes, their routine use often presents more risks than benefits and can  have unexpected side effects.  And nowhere are birth interventions used more routinely than in the births of "obese" women. 

If they truly want to improve outcomes in women of size, caregivers MUST start examining how their own attitudes and interventive practices influence outcomes both positively and negatively.

Poly Cystic Ovarian Syndrome (PCOS)

I keep waiting for mainstream researchers to have anything meaningful to say about PCOS (a metabolic disorder found in many "obese" women) and breastfeeding as well.

Some research (and a lot of anecdotal evidence) shows that severe PCOS often affects breastfeeding supply. So how much of this reduced breastfeeding rate in "obese" women is due to PCOS supply issues, and how much isn't?

How come very few of these breastfeeding and obesity studies even mention the possibility of PCOS affecting milk supply? 

Most of the "lower breastfeeding in obese women" studies only mention a study done in 2004 that showed a lower prolactin response in "obese" women in response to nursing.

So now all these studies blame obesity for lower prolactin response to suckling.......when actually it could be PCOS causing disturbances in the mother's metabolism and hormones, which in turn causes problems with lactogenesis and obesity. From the article on PCOS and low milk supply at MOBI:

According to Lisa Marasco, the IBCLC whose breakthrough research revealed the connection between PCOS and low milk supply, there are several different ways that PCOS could potentially interfere with breastfeeding.

1. Due to the hormonal imbalances which occur, there is the potential for poor breast tissue development during puberty and pregnancy. Fewer menstrual cycles in early puberty can translate into less estrogen to develop mammary tissue.
2. Prolactin and oxytocin are two of the main hormones involved in the onset of lactation. Women with PCOS have higher levels of androgen hormones that can interfere with prolactin reaching its receptors.
3. In addition, if too few prolactin receptors were formed during pregnancy, milk production will be limited.
4. Estrogen is known to inhibit lactation, particularly in the early days after delivery. Women with PCOS typically have an imbalance called “estrogen dominance.” If estrogen levels are not down-regulated after birth, circulating estrogen may interfere with lactation. This is why the contraceptive pill is not recommended for breastfeeding mothers.
5. Insulin resistance may affect breast growth and milk synthesis. Insulin is known to be an important factor in lactation in conjunction with prolactin and cortisol.

[In addition, more than one study also shows that prolactin response was lower in women delivered by cesarean, so that may be a synergistic factor as well.]

Where are the studies looking at these possibilities?  Lisa Marasco made research on PCOS and low supply the topic of her Master's thesis, but she is one of the lone voices in the wilderness. She first published about this in 2000.....it's been 10 years since her initial work was published, yet only minimal new work on this has been published since then. 

There have been a few studies here and there, and one comprehensive review of obesity and breastfeeding does mention PCOS as a possibility in passing, but really, after all these years, why isn't more being done on the PCOS/breastfeeding connection, and why isn't there more acknolwedgement of the connection in the research reviews?

Hypothyroidism

Many "obese" people have higher levels of TSH...not always enough to get formally diagnosed with hypothyroidism, but generally higher than in people of average size.

This may indicate that many fat people actually have a form of subclinical hypothyroidism......not quite severe enough to be diagnosed or treated with current diagnostic guidelines, but severe enough to cause symptoms and difficulties with metabolism.

There is currently a strong debate whether or not people with subclinical hypothyroidism and symptoms of the Metabolic Syndrome should be diagnosed and treated with thyroid meds. [I believe they should.]

We know that more severe hypothyroidism can affect milk supply; might borderline cases also have higher rates of supply difficulties?  I strongly suspect it has a role as well for many women.  And since a higher number of women with PCOS have hypothyroidism, there may be a combination of factors at work here.

Anemia

Anemia is another possibility. It can affect milk supply too.

Obesity itself has been associated with higher rates of postpartum anemia, although whether this is secondary to increased interventions is unclear.

Postpartum hemorrhage can be associated with insufficient milk supply.  Cesareans can increase the rates of anemia due to increased blood loss during surgical delivery. Yet many doctors fail to routinely check for anemia after a cesarean, even when the woman is symptomatic.

If a high rate of "obese" women are undergoing cesareans, might undiscovered or undertreated anemia be playing a role in delayed lactogenesis?

Furthermore, hypothyroidism is often associated with iron-deficiency anemia and low ferritin (stored iron) levels, so it's possible that if fat women have a higher rate of borderline hypothyroidism, they might also have a higher rate of anemia.  Could the two factors be synergistic?  Especially if combined with a stressor like a cesarean?  And PCOS issues?

Perhaps it is not so much one physiologic factor as it is several combining factors.

Psychosocial Factors

Other factors may be psychosocial in nature, not physiological, and a few reviews of breastfeeding and obesity do take time to discuss these possible factors.

The 2007 review focused a lot of attention on "intention to breastfeed."  In other words, obese women planned to breastfeed far less often than women of average size.  In smokers (another group with lower breastfeeding rates), intention to breastfeed is very tied to actual breastfeeding rates, so the authors speculate that this is a significant (and overcome-able) factor for fat women too.  This is a valid point.

Now, why obese women would intend to breastfeed less than other women, it's hard to say.  If there are more obese women in lower socioeconomic groups, and if women in lower socioeconomic groups tend to breastfeed less, the association may merely be coincidental.  Or it may also be a subtle reflection of years of internalized fat-phobia.

After years of being told their body was "defective" or didn't "work right," fat women may simply be all too ready to believe that they "can't" breastfeed and give up easily....or decide not to bother trying in the first place. 

This sounds simplistic but I believe it is a powerful force behind women of size not breastfeeding as much or as long as other women.  Never underestimate the toll that years of negativity have on a woman's self-confidence in her own body and willingness to trust in its ability to work "right."

Some fat women face outright discouragement from medical professionals, who may tell them that they'd never make enough milk for a big baby or that their breasts are "too large" to breastfeed successfully, or that they'll "suffocate" the baby. 

Or they may receive more subtle discouragement ("that little baby will have problems latching onto that large nipple") or not receive the same level of support and encouragement as women of average-size because the healthcare professional believes that they are a lost cause.

A difference in breast size and feeding mechanics may also play a role.  Really well-endowed women may need to adapt the hold they use for nursing (for some like me, the football hold is the only hold that works).  Of course, not all fat women have large breasts, but enough do that not providing adequate instruction  about nursing with large breasts means that many fat women will find it difficult and frustrating to figure out how to manage their differences and may give up quickly. 

In addition, breastfeeding books and videos rarely feature pictures of women with large breasts breastfeeding, so there are few pictures to inspire women with larger breasts to try.  Some breastfeeding books don't address how to adapt for these differences.  Others do, but the hints they give may be suitable for the "D" cup woman but not the J, I, or O cup woman. (Propping your breast with a rolled-up washcloth doesn't usually work for the O cup woman!)  Many lactation specialists really don't "get" the special needs of women who are extremely well-endowed and don't have much useful advice for them.

Furthermore, there is a real lack of breastfeeding-friendly gear in larger sizes.  Although some companies now carry nursing bras in larger band sizes and larger cup sizes, they can be hard to find if you don't know where to look.  Most fat women certainly can't go in to a maternity store in the local mall and buy a nursing bra or a nursing top, so that can act as yet another subtle discouragement from long-term breastfeeding.

And almost never is there a picture in breastfeeding books of a woman of size (regardless of cup size) breastfeeding at all. While I'm sure the authors never mean to imply that fat women can't breastfeed, it's the underlying message that comes across when there are no pictures of women of size breastfeeding.

Just as we desperately need more images of women of color breastfeeding, we very much need pictures of women of size breastfeeding too.  And how about some breastfeeding pictures of women of color who are also women of size?

Summary

The lack of pictures showing fat women breastfeeding, the lack of breastfeeding gear for women of size, the subtle and not-so-subtle negative feedback about breastfeeding when well-endowed, and the sometimes blatant discouragement away from breastfeeding combine with the negative self-image some fat women have to strongly discourage fat women away from even considering breastfeeding. 

Add in the extremely high rate of interventions around labor and birth in women of size, then any issues with hypothyroidism, anemia, or PCOS, and is it any wonder that "obese" women have lower breastfeeding rates? 

The above are only a few possible factors; there may certainly be others at play as well. If it's that easy for me as a non-healthcare professional to come up with possible reasons, why can't the professionals do so? Why won't they investigate these other possibilities seriously? Why don't they even mention these as possibilities in their studies?

Answer:....because they like simplistic answers, and because it suits the anti-obesity agenda of some researchers to blame every problem on obesity. If the problem is obesity, then the "fix" is to lose weight, right?  Simple problem, simple solution, no messy complicating details.

Furthermore, what financial reason do they have to study breastfeeding in women of size in more detail?  It's far easier to make a quick publishing hit by noting a lower rate of breastfeeding in women of size, tsk-tsking over it in the media, and promoting it as another reason to lose weight --- without having to inconveniently prove that losing weight improves breastfeeding outcomes.

The story is almost surely more complex than that.

My Own Story

This is admittedly a hot-button subject for me.

Breastfeeding with my first baby was almost completely torpedoed because of classic cascade of interventions: long hard induction, cesarean, severe edema from pitocin and copious IV fluids, 8 hours of separation before I was allowed to start nursing, frequent formula and glucose water supplements given by the staff, a sleepy baby from jaundice and all the drugs, etc.  Add to that a mother in severe pain, little information about how to adapt breastfeeding for larger breasts, and a lifetime of "your body is broken" messages, and you have a classic recipe for breastfeeding "failure."

It's actually a miracle we managed to preserve breastfeeding at all. It was three months before everything really worked out, and I really considered giving up many times. Frankly, the only reason I kept going was because my MIL and SIL had breastfed for 4 months each and I wanted to prove that I could too. Then suddenly, things turned around between month 2 and month 3, and things worked out. We ended up doing extended nursing....but it was a very close thing in the beginning.

I had no problems breastfeeding my later babies, but breastfeeding almost "failed" with my first. The only major difference was in labor management and neonatal interventions, so I'm convinced that interventions plays a very strong role in the lower breastfeeding rates in women of size.

My first labor was the only one where I had so many interventions during labor and where my baby had so many interventions after birth.  I had another labor and c-section with #2 but there were no induction drugs, minimal IV fluids, no separation after the birth, frequent and early nursing, and NO formula, pacifiers, or bottles of any kind. Same mother, similar delivery (labor and c-section).......but a totally different outcome. Yes, I'd breastfed before, which helps.....but I think the difference was labor interventions and management. 

And things were even easier with the next 2 babies, my VBAC babies. No c-section to separate us at all or to delay my milk coming in. 

You CANNOT tell me labor management and neonatal interventions don't matter. 

And why did I have all those labor interventions with my first child?  Because of a high-intervention management style the OB used due to my weight.

Correlation is not causation.  Sometimes factors other than obesity are at work when breastfeeding doesn't work out.  Wouldn't it be nice if this were acknowledged in these studies?

And when there is a physiologic cause, such as PCOS, wouldn't it be nice if there was more acknowledgement of that fact, and more meaningful research into how to mitigate that issue?

Conclusion

There are so many of us fat moms who HAVE breastfed successfully, not just for a few months but long-term as well. Why is it rarely mentioned that many fat women DO breastfeed just fine?  Where are the stories and pictures documenting successful lactation in women of size?

If fatness truly caused poor lactation, then no fat women would be able to breastfeed.  The truth is that some do and some don't, so there are likely multiple factors at work here, not just "obesity."

Why aren't they studying the fat women who HAVE breastfed successfully long-term and comparing them to the ones who haven't and see what the differences are? I bet that'd show some interesting differences.

In my observation, those differences usually relate to severity of PCOS, hormone levels, and/or high-tech labor management, delivery mode and neonatal interventions....but no one wants to hear that.  They'd rather just take the easy way out by blaming obesity and assume that losing weight is the best answer for fixing the problem. 

There needs to be more MEANINGFUL research on this topic instead of just simplistic sensationalism that discourages and blames fat women instead of encouraging and empowering them.  Ugh. 

Are you listening, lactation consultants and maternity care providers?

*Special note to the moms of any size out there who had difficulty or were not able to breastfeed: I have a special empathy for this situation because of how close I came to "failing" at breastfeeding with my first.  Please don't read into this article any criticisms of you.  I know you did the best you could and in no way are you a "lesser" mother for not being able to breastfeed. I simply want to point out the need for the research on obesity and breastfeeding to be more complex and meaningful.

**If you would like compassionate support for breastfeeding difficulties, please check out the MOBI site (Mothers Overcoming Breastfeeding Issues).  This is a great site for women who have had difficulty breastfeeding, and offers information and non-judgmental support whether you continue to breastfeed or decide you need to stop.  It can help you you get to the root of low milk supply, learn more about improving breastfeeding, or grieve a difficult or lost breastfeeding relationship.  I can't recommend the site highly enough.

***Breastfeeding picture by Stanisław Wyspiański (1905), found at Wikimedia.

****If you are a woman of size and you are willing to share a picture of you breastfeeding for this blog or for my general use as needed, please send me a note at kmom at plus-size-pregnancy dot   org and be sure to give me permission to use the picture.  As noted, I am particularly interested in having more images of fat women of color in pregnancy, birth, and breastfeeding.