A Slim Chance?

They are as sick that surfeit with too much as they are that starve with nothing

Although the word ‘obesity’ was not used until the beginning of the 17th century, the suspicion that there was something distinctly unhealthy about it has been with us for millenia –certainly long before Shakespeare’s The Merchant of Venice was written. There was a time, of course, when food was scarce and so its acquisition and display was considered a sign of wealth and power. Only the more extreme examples of over indulgence seemed to stand out as unhealthy and undesireable. But it’s true that our standard of acceptance has varied over the centuries; our idea of what is normal is very much influenced by what we see around us (as I have commented in a previous essay: https://musingsonwomenshealth.wordpress.com/2015/04/02/nudging-childhood-obesity/)

There seems little question as to the adverse health problems associated with obesity, but I suppose the most worrisome aspect of its increasing prevalence is what is to be done about it. There have been those who have felt that to condemn it is to discriminate unfairly –unjustly attributing fault (and guilt) where there should be none. The International Size Acceptance Association (ISAA) for example was founded in the USA in 1997 to promote acceptance of excessive weight and end weight-based prejudice. But, by and large, there has been a general realization that unless something is done about it, the burden of obesity will result in a parallel but undue burden not only on health itself but also the facilities necessary to deal with its consequences.

So the challenge is staying abreast of the problem: treating it, or better yet, preventing it. There was an interesting article in a July 2015 BBC report about some of the problems with our approaches to the issue so far: http://www.bbc.com/news/health-33551498 Using UK data, ‘The research tracked the weight of 278,982 men and women between 2004 and 2014 using electronic health records.’ And the findings from this huge data base were disappointing: ‘For obese people (with a Body Mass Index of 30 or more), the annual probability of slimming down was one in 210 for men and one in 124 for women.

This increased to one in 1,290 for men and one in 677 for women with morbid obesity (BMI 40 to 45)’. In other words, ‘Current strategies that focus on cutting calories and boosting physical activity aren’t working for most patients to achieve weight loss and maintain that.’ http://ajph.aphapublications.org/doi/pdfplus/10.2105/AJPH.2015.302773

There are, of course, other strategies –bariatric surgery probably the most successful of these. This is an approach that attempts either to restrict the amount of food that can access an adequate amount of bowel to be processed, or conversely to restrict the amount of processing (absorption of nutrients): http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3470459/

Quite apart from the fact that it is a surgical –ie invasive- approach, and requires both facilities and trained surgeons to perform, is expensive, and would not be scalable to the requirements of a large and increasingly needful population, it is not without problems. Depending on the study, there are complications in as many as 17% of cases, and even a need for re-operation in 7-10%. New data will emerge as methodologies improve, no doubt, but even if complications dropped to zero –an almost naïve fantasy- it would still not serve the needs of the vast majority of obese people.

No, it seems to me that the only viable option is that of primary prevention –establishing a culture of healthy eating, and an expectation of a more healthy weight spectrum. But even to say that, courts another naivete, namely that wishing it were so –knowing that it makes sense- is a view held by everyone. Were it not for the stigma of weight, how many would realize there was even a need for change? And is the stigma itself more of an impediment than an incentive to weight reduction? I found another study, this one with more of an emphasis on social justice than answers: http://ajph.aphapublications.org/doi/abs/10.2105/AJPH.2009.159491 And as the authors suggest in their abstract –again in the American Journal of Public Health: ‘On the basis of current findings, we propose that weight stigma is not a beneficial public health tool for reducing obesity. Rather, stigmatization of obese individuals threatens health, generates health disparities, and interferes with effective obesity intervention efforts.’

So, clearly the solutions must come from within –much as you have to want, say, to quit smoking before you will even hear the message. Maybe Shakespeare again, hinted at this when, in his play Julius Caesar, he has Cassius say to Brutus:

And since you know you cannot see yourself
So well as by reflection, I, your glass,
Will modestly discover to yourself
That of yourself which you yet know not of.

It’s a thought, anyway…

Should IVF be denied to Obese Women?

Obesity has a long and chequered history. Different cultures have both defined it and viewed it differently: in some it was a sign of wealth and was seen as desirable; in others, a sign of weakness, dysfunction, sloth. I use the past tense advisedly, given the rise of fast food outlets throughout the world and their putative role in the rise of obesity in all social strata. Adiposity wears different clothes today.

The classification of weight is now largely dependent on measurement of the Body Mass Index (BMI) -(calculated by dividing the person’s mass -weight- in kilograms, by the square of their height in meters. i.e. M/H x H). In North America, at least, ‘Normal’ weight is less than 25; Overweight is 25-30; Obese is greater than 30. The levels assigned for each category are somewhat arbitrary, however, and various countries -perhaps reflecting differences in diet, genetics, or their own studies- have defined them quite differently.

Obesity, then, is a chimera -a culturally enhanced improvisation; there is little argument about the extremes, but much debate in the middle ground, and therefore about the value at which to begin an intervention -and the resultant stigmatization- if it is solely on the basis of BMI. Not all large people are unhealthy, and neither hypertension nor diabetes, for example, are restricted to that population. So, to base important judgements -with their attendant far-reaching effects- on the measurement of BMI alone is more of a societal bias, a cultural bigotry, than a well-founded and scientifically validated decision.

I am not arguing that excess weight is healthy -or even desirable- but suggesting that to justify treatment decisions on BMI alone risks applying generalizations that are useful when dealing with large populations, but inadequate when considering individuals. No one of us is the herd. And the distinction is an important one.

For example, there seems to be a constantly-shifting move afoot to deny fertility treatments -especially in vitro fertilization (IVF)- to obese women.  Canadian MDs consider denying fertility treatments to obese women   It is based, apparently, on several factors: success rates tend to be lower in this group; the procedure is technically more challenging, and the woman is more likely to suffer complications in the pregnancy that may jeopardize both her and the foetus. The fact that in some jurisdictions, the first one or two treatments may be covered by a government subsidy, suggests that there might also be a feeling that the taxpayer’s money could be better spent on projects more likely to succeed. Or perhaps on issues that benefit more of the electorate.

I have to admit I am conflicted in this. One likes to hope that funds -be they private or public- will be well spent. That there is a reasonable likelihood of success. That the risk/benefit ratio is weighted in favor of the funder. And if this is not the case, then it should be made perfectly clear at the start; the outlook honestly explained, lest expectations trump reality.  http://www.creatingafamily.org/blog/obese-women-banned-vitro-fertilization/

But hope is often unquenchable no matter the argument, so what is an infertility clinic to do? Obviously there have to be some standards for IVF. BMI may well be one of them, but as I have suggested, this is likely only a rough guide to success and seems to have discriminatory overtones, no matter the data.

In medical ethics, decisions are often guided by a few simple principles: Autonomy -the right of an individual to make an informed decision; Beneficence -promoting the health and well-being of others and attempting to serve their best interests; and Non-Maleficence -not intentionally doing them harm (primum non nocere). It is the last of these that seems the most problematic for the IVF clinics. Should they knowingly embark upon a treatment -an elective treatment at that- which may have adverse consequences for their patient? The argument has been raised that doctors don’t apply the same values with respect to dealing with, say, smokers or alcoholics that they do with obese infertile women -all of whose problems are often considered to be self-inflicted, at least by society at large. The argument, of course is specious: the condition of infertility, however unfortunate, is not comparable with emphysema, lung cancer, or liver failure…

I think that a more reasonable approach would be to divide the risks both to the obese woman and her foetus into what I will term heedless risk and assimilable risk. It would be irresponsible, for example, to consider IVF in an older woman, obese or not, with severe, unstable and longstanding insulin-requiring diabetes with hypertension and end stage renal failure -the risks are far too great and the outcome unpredictable at best. Contrast that with a large woman -otherwise healthy- whose only risk is her weight. Yes, there may be technical challenges for the IVF, and each of these would need to be assessed on its own merit and risk; and yes, obese women do have a higher likelihood of pregnancy complications, but so do normal weight women who have, say, pre-existing hypertension, or SLE (lupus). And what about obese women who have become pregnant on their own? We struggle through pregnancies with them…

So I suppose the issue is not so much the risk as the guilt of complicity. The sin of acquiescence: collusion with the woman’s dreams of having a baby. Of actively fostering it. Stepping out of the role of omniscient parent and into the character of enabler. But to see it this way, is to be blind to the other equally important, and yet often forgotten ethical principle: Autonomy. If the risk is assimilable, does the patient not have the right to participate in the decision? Is this not also a requirement of that third principle, Beneficence: serving what she perceives to be in her best interest?

It’s a difficult issue, to be sure, and there’s likely no algorithmically valid approach to its resolution. But in the end, we’re humans, not flow charts -our minds simply do not function well that way. Decisions are not unidimensional, because we are not. Let judgements be based not on the letter of the textbooks, not on the litany of complications, nor on the statistical analyses of non-players, non-actors in the drama. As with the Law, let us consider the spirit in which it was written; details are important, but so are people. Even if they happen to be obese.