Weight and See

 

Obesity and dietary issues have been seen as major contributors to diabetes and cardiovascular health for some time now. No longer regarded as outward manifestations of status or wealth in most societies, they are now often subjects of disparagement, and those carrying extra weight frequently stigmatized and derided. As if the very fact of being overweight was an act of moral depravity, or at the very least, a manifestation of weakness. Self-neglect.

Smoking –especially in North America- suffered a similar fall from grace when it became evident that it was a cause of major health problems. But it is much easier to hide a smoking habit than an overweight or frankly obese body. And whereas public measures to stigmatize smoking and outline the health risks may have some effect on smoking behaviours or smoking persistence, they seem to be counterproductive in successfully encouraging exercise for weight loss according to a large study from Britain: http://bmjopen.bmj.com/content/7/3/e014592

This was a long term study starting in 2002 of 5480 participants of both sexes, all at or over 50 years of age, and carried out by Dr. Sarah Jackson from University College London. ‘In summary, these results provide evidence that weight discrimination may be associated with lower participation in regular physical activity and higher rates of sedentary behaviour. Through this mechanism, weight discrimination may be implicated in the perpetuation of weight gain, onset of obesity related comorbidities and even premature mortality.’

The BBC News also reported a perhaps more easily assimilable summary of the study: http://www.bbc.com/news/health-39191100. The point being, evidently, that shaming or drawing attention to the weight a person is carrying is less likely to get them to exercise than a welcoming and supportive attitude. And environment -‘Exercising when you are overweight can be daunting, and the fat-shaming attitudes of others do not help.’

I suppose this study is much like carrying coal to Newcastle, but nonetheless it is important to hold a mirror to societal attitudes and prejudices. It’s often not so much that we mean to denigrate people who hold different values, or who do not seem to espouse the image we find attractive but rather that we hold ourselves apart. Withholding approval can be as devastating as active discrimination and, at least in this case, seldom leads to positive changes.

Unfortunately the problem of excessive weight sometimes slips by in a gynaecology office as well –noticed, but unmentioned- because of fear of upsetting the patient. Occasionally, an opportunity will present itself, however. One has to be alert –and sensitive.

Janina was a new patient to me. I first saw her in the waiting room sitting in the corner seat which was partially obscured by a large, leafy Areca palm. Her head and face were further hidden behind a magazine whose pages never seemed to turn. A large lady by any estimation, she attempted to camouflage it as best she could with an extra-large, loose fitting brightly patterned sweat shirt and bulky jeans. The effect was really quite beautiful –and so was Janina when she finally lowered the magazine. Her large, brown eyes were captive birds that fluttered delicately behind the bars of exquisite eyelashes. Her face was soft and her smile, although timid and infrequently offered, was captivating. She wore her hair long and auburn waves flowed slowly and gently over her shoulders like water on a beach whenever she moved.

She made a show of being nice in the waiting room, but I could tell that she was uncomfortable as she followed behind me to my office. She closed the door quietly behind her but before she sat she moved the chair as far away from the desk as the room allowed.

I smiled at her in an attempt to put her at her ease, but she had already dropped her eyes onto her lap and refused to retrieve them.

“Dr. Blackstock says you are having some problems with your birth control pills,” I said, when it became evident that she was not going to volunteer any information.

She sat perfectly still, her hands clasped motionlessly where her eyes still lay. Finally, she took a long, slow breath, looked at me, then slowly nodded her head. It was a sad movement, and for a moment, I wondered if she was going to break into tears. But she remained silent.

“What kind of problem are you having, Janina?” I asked, after another sepulchral moment.

She sighed again, but her face changed. “Isn’t it obvious, doctor?”

I raised an eyebrow to indicate that it wasn’t.

“Ever since I started on the pill, I’ve continued to gain weight,” she started. “I was never this heavy before…” She paused briefly to let that sink in. “Never…” She let her eyes drift around the room for a moment, finally settling them on a terra cotta statuette of a seated woman with a begging bowl that I’d placed on a little oak stand in the corner. “I don’t want to end up like her,” she said, pointing at the woman. She sent her eyes back to perch briefly on my face. “But even she isn’t as fat as me…”

As the words sank slowly into silence, a tear began to run down her now quivering cheek. I rose from my desk and walked across the room to hand her some tissues. She seemed to appreciate the gesture and her face softened for a moment. In fact, she used the opportunity to examine me as I walked back to my desk.

“You have no idea how people look at a fat person like me…” she finally volunteered and then her eyes focused on a wooden figurine on my desk behind a plant; it was a woman holding a child and peering out as if she were hiding. “I feel like that woman,” she said, nodding at the plant with her eyes.

I must have let a worried expression escape onto my face, because Janina seemed to focus on it. “It’s a different world when you’re fat, doctor. That’s all people see…”

I sighed. I couldn’t help it; she seemed so sad. “I see beauty,” I said –it just escaped from my lips. I hadn’t planned it…

Suddenly she smiled, and her hair danced once again over her shoulders. She straightened herself on the chair, and then with a gentle shrug stood and moved it closer to the desk.

 

 

 

 

Barbie in the Mirror

As an Ob/Gyn specialist I have been, I suppose, more than a passive observer of women over the years. But society has not been passive, either. Depending on where you live and in what cultural milieu, issues such as our sizes and shapes have become sources of real anxiety. Unrealistic expectations of morphology no doubt arise from multiple origins, but the end result is often the same -many of us don’t even come close to meeting them.

And as if that worry wasn’t enough, there has now been added the perhaps more troublesome issue of health. Despite the euphemism ‘plus-sized’ there is no disguising the stigma of the special term for many women –particularly when it comes wrapped with innuendoes of obesity and diminished well-being… not to mention beauty. Shakespeare would have us believe that ‘Love looks not with the eyes but with the mind.’ But does it? https://blogs.harvard.edu/marianabockarova/2014/05/29/the-science-of-beauty/ Once again, morphology rears its stilted head.

But we are a curious lot, we humans, influenced as we are by fashion and culture. Fickle in our choices, mercurial in our attitudes to those who fall outside the norms, we deride those who fail to satisfy the arbitrary boundaries –temporal though they may be.

Some have argued that one of the barometers of expectation is the shape of dolls –Barbie dolls in particular. They become, after all, the matrix of imaginary play and serve as proxies for the roles the children are trying to understand. http://www.bbc.com/news/magazine-35670446

A fuss seems to have been engendered by the release of three new types of Barbies: curvy, petite and tall. There are also skin colour differences, presumably to reflect the diversity in modern societies. But also, one could argue, to deflect the criticism of pandering to the thin, blond phenotype so prevalent in their models up to now. ‘Mattel [the makers of the doll] argues Barbie shouldn’t be expected to represent average proportions in the first place. “Barbie is a doll. She is not meant to reflect a real woman’s body,” says Sarah Allen from Mattel UK. “The purpose of introducing three new bodies into the range is variety and differentiation. When you look at the dolls collectively you can see the range in relationship between the dolls. “’ It’s a start, I suppose.

Therein lies the problem, of course, and it seems to me that it is hydra-headed. On the one hand to portray a doll that is truly representative of the reality that the child sees around her, would be to normalize –legitimize, really- the scourge of the 21st century: obesity and all of the health risks that entails: ‘[…]were Mattel required to accurately reflect the average British and American woman across all ages, the dolls would be overweight or obese.’ And yet, from a more modulated perspective, ‘Lenore Wright, from Baylor University, Texas, conducted a study in 2003 that explored the role of Barbie. She found Barbie’s shape didn’t really matter to children – her function was more important.’ Dolls, in other words, are just pretend –they’re substitutes that are merely assigned the role the child is exploring. The child knows they are not real.

But ‘Wright adds that Mattel’s new line has been criticized by some feminist scholars for reinforcing an old stereotype – that women are defined by their bodies.’ As I suggested, there are many divergent perspectives but remember that a Minotaur waits at the center of the labyrinth. We must be careful not to wander too far in our approach; we must not let our zeal mislead us.

It seems to me that children have always played with dolls and represented them according to their needs. To criticize a stick-doll, for example, or to confuse it with the reality the child apprehends is to stray dangerously far into revisionism. We are not children and we do not think as children. In a world where dolls are doctors, and dogs are patients, we are now strangers. Adults. Other… Forgive me for referencing Corinthians, but I think its advice was prescient: ‘When I was a child, I spake as a child, I understood as a child, I thought as a child: but when I became a man, I put away childish things.’

Amen to that.

 

 

 

 

 

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…

The Body’s Clock

Scientists –well, all of us- have been suspicious about the health risks of shift work for a long time now. Perhaps there is a reason buried somewhere in our genes that suggests night is for sleeping and daytime for working. Originally, no doubt, it was because it was difficult to see things in the dark and lighting, even when it became available, wasn’t very good.

But there is another reason: the Circadian Rhythm (from the Latin circa –around, and dies –day) which is often defined as physical, mental and behavioral changes that follow a roughly 24-hour cycle, responding primarily to light and darkness in an organism’s environment. The body clock, in other words. And there’s the clue: light and darkness. These are not just elements in our environment that we have come to expect, they actually have a biological meaning for us although this is, to a certain extent, entrainable. Malleable. As Wikipedia (sorry!) puts it: The rhythm can be reset by exposure to external stimuli (such as light and heat), a process called entrainment. The external stimulus used to entrain a rhythm is called the Zeitgeber, or “time giver”. But it can take a while to adjust –think of jetlag, or sleep disturbance after starting a new shift at a different time.

The body can adapt to many things, no doubt; the problems seem to arise when the pattern keeps changing. As folk wisdom attests, we are inherently creatures of habit –acquired behaviour patterns that are repeated so frequently they can become almost involuntary. As no less an observer of folkways than Samuel Johnson once said: “The chains of habit are too weak to be felt until they are too strong to be broken.” So one might ask why we –and many other animals- seem prone to develop these routines, these almost unconscious ceremonies. Is it simply a need for predictability? Or is it something deeper, something tied to our evolutionary past..?

In our evolutionary development we obviously experienced disruption of light/dark cycles –they occur as we travel through the seasons- but these are gradual and steadily progressive; shift work –especially rotational shift work- is not. And only recently has it become more obvious that there may be a price to pay. There have been several studies that have looked at this in various ways, but ‘Although epidemiological studies in shift workers and flight attendants have associated chronic circadian rhythm disturbance (CRD) with increased breast cancer risk, causal evidence for this association is lacking’ as the abstract of a paper published in Current Biology noted. I saw this in a July 2015 article in BBC News reporting on a study co-authored by Dr. Kirsten Van Dycke which suggested that the chronic need to re-entrain the circadian rhythm because of changing light/dark cycles can increase the risk for both obesity and breast cancer! http://www.bbc.com/news/health-33569161 Now, admittedly, the study was done on mice who were prone to develop breast cancers anyway, but when the light/dark cycles were switched over a long period of time (‘Mice prone to developing breast cancer had their body clock delayed by 12 hours every week for a year’) they developed them sooner.

Humans are obviously not mice, but it is difficult to control for possible contributing factors in the average human study: ‘Several scenarios have been proposed to contribute to the shift work-cancer connection: (1) internal desynchronization, (2) light at night (resulting in melatonin suppression), (3) sleep disruption, (4) lifestyle disturbances, and (5) decreased vitamin D levels due to lack of sunlight. The confounders inherent in human field studies are less problematic in animal studies, which are therefore a good approach to assess the causal relation between circadian disturbance and cancer.’ http://www.cell.com/current-biology/abstract/S0960-9822(15)00677-6

And the conclusion from this study? ‘Animals exposed to the weekly LD [light/dark] inversions showed a decrease in tumor suppression. In addition, these animals showed an increase in body weight. Importantly, this study provides the first experimental proof that CRD [Circadian Rhythm Disturbance] increases breast cancer development. Finally, our data suggest internal desynchronization and sleep disturbance as mechanisms linking shift work with cancer development and obesity’.

This is worrisome, to say the least. One could certainly argue that a woman with an increased risk for breast cancer –say a heditarily aquired BRCA1/2 mutation- would be best to avoid jobs involving chronic irregular body clock disturbance such as flight attendants, commercial pilots, and so on. But I’m not sure the risk is confined to that population. What about others –especially if they have additional life-style risks such as smoking, diabetes, alcohol issues?

And what about men? If –as the study suggests- a chronic body clock disruption may cause a decrease in tumour suppression, would that not suggest a similarly increased risk? The disruption also seems to have an additional risk for increased weight gain –obesity. Is the risk for type 2 diabetes therefore also increased? Clearly this is an area requiring much more research -further elucidation of the mechanisms involved and mitigation strategies at the very least. Sleep is so important –regular sleeping patterns…

I can’t help but remember the words of Shakespeare’s Macbeth talking to his wife after he has killed Duncan, the king:

Methought I heard a voice cry, “Sleep no more!

Macbeth does murder sleep”—the innocent sleep,

Sleep that knits up the raveled sleave of care,

The death of each day’s life, sore labor’s bath,

Balm of hurt minds, great nature’s second course,

Chief nourisher in life’s feast.

Art, once again, anticipating Science…

Nudging Childhood Obesity

When I was a kid, obesity was not the norm. Admittedly, this was a long time ago, and no doubt I only remember brief and highly selective snippets of the time –modified, no doubt, to serve whatever demands are required in the present. But in these unexpurgated, sketches, I have memories of labeling the occasional child in the playground as ‘fat’. Whoever it was stood out from the rest –ex gregis in the true etymological sense of the word ‘egregious’- and so through the insouciance of childhood, were forever condemned to wear the epithet like a poorly fitting sweater.

Maybe we just didn’t have enough to eat in those halcyon days of early Winnipeg; maybe the winters were too severe and the necessary clothes too heavy to allow the accumulation of excessive girth. But let’s face it, normal is what we see around us. It is parochial. It is the statistics of one box. And yet, isn’t that how we judge: by what we know? If I am obese, and my child is too, then what’s the problem? And if all his friends, and all my friends are large, then how am I to adjudicate another norm? Thin is aberrant, not fat.

I came across an interesting article in Forbes magazine reporting about a study –several studies, in fact- demonstrating the inability of parents to judge whether or not their child was overweight: http://www.forbes.com/sites/alicegwalton/2015/03/30/can-you-tell-if-your-child-is-overweight-most-parents-cant-study-finds/

This is worrisome, to say the least -unless of course you change the definition of what weight is normal… But no matter the norm, health risks for diabetes, hypertension and cardiovascular disease generally increase with increasing BMI (Body Mass Index -which is the weight in kilograms divided by the square of the height in meters: kg/m2).

And it is difficult to rationalize the increasing prevalence of corpulence in the population as an evolutionary process. It’s hard to understand how plumpness would be of any survival benefit, or why it would be selected for in a gene pool. There exist islands of controversy in this, of course: http://www.bbc.com/news/magazine-28191865  But I think most analyses would suggest that obesity (BMI >30 -at least in North American population studies) adversely influences health and life span. So it would make sense to attempt to correct the issue as early as possible.

As an obstetrician, I am drawn to the idea that management of pregnancy and birth weight are important. I was intrigued by a prediction model I saw reported in the BBC from 2012 suggesting the risks for subsequent obesity of a child could be predicted at birth with about 80% accuracy: http://www.bbc.com/news/health-20509577  I haven’t seen much about this recently, so I don’t know how well it has stood the test of scientific scrutiny, but at least it was an interesting thesis. A start.

Recently, the Canadian Task Force on Preventive Health published an update on childhood obesity guidelines: http://www.cbc.ca/news/health/child-obesity-charts-open-door-to-treatment-1.3014832  It contains the usual admonitions against junk food and physical inactivity, of course, but advocates some innovative strategies, I think. For example, because the circadian rhythms of teenagers have been found to differ from the adults who are teaching them, it recommended starting classes later in the morning and suggested breaks in each class. And walking to school, where feasible, as part of the exercise regime… Dr. Brian Goldman, host of CBC’s ‘White Coat, Black Art’ program, while agreeing with the guidelines, detected some downsides to the recommendations however: http://www.cbc.ca/radio/whitecoat/blog/the-cure-for-childhood-obesity-parents-will-hate-1.3014981

The contributing factors to obesity –let alone childhood obesity- are legion: genetics, dietary habits, social milieu, parental influences, environmental conditions, Media, socioeconomic status, and peer group expectations, to name a few. None are solely responsible, but unless there are some counteracting forces –incentives- all are important. Behaviour, habits, and expectations are learned phenomena and it may be something as simple as imitation of parents or friends that starts it off and then sustains it.

When faced with uncountable opponents and overwhelming odds, how can Society possibly succeed in changing things? Well, simplistically, it needs to change attitudes. Change what the majority considers acceptable. Change the mythos. It is slowly changing the acceptability of smoking as a norm; even the legitimacy of drinking and driving is under scrutiny –not only in the courts but also in the minds of drinkers. Some things are just not seen as cool nowadays.

But, given the importance of preventing childhood obesity for the health and well-being of future generations and given the relative lack of success so far, I think we need a new (old?) approach. There is a freshly-named, although age-old practice, termed ‘Nudge Theory’. It is a euphemism that my mother would have simply called manipulation because, although cleverly disguised, that’s really what it is. Wikipedia has succinct explanation: Nudge theory (or Nudge) is a concept in behavioral science, political theory and economics which argues that positive reinforcement and indirect suggestions to try to achieve non-forced compliance can influence the motives, incentives and decision making of groups and individuals, at least as effectively – if not more effectively – than direct instruction, legislation, or enforcement. Here are two introductions –take your choice:  http://www-2.rotman.utoronto.ca/facbios/file/GuidetoNudging-Rotman-Mar2013.ashx.pdf or http://www.businessballs.com/nudge-theory.htm

Education, and early identification and treatment of those at risk of becoming obese are obviously important and desirable, but I think we need something more. Something with a proven track record, albeit in different fields. Maybe ad campaigns and directed manipulation –sorry, nudging– would be valuable adjuncts. We are media savvy nowadays, and used as a tool for change, it seems ideal. As long as we are certain of our goals, and the science is correct, I think it is an ethically acceptable approach, and one with great potential.

I did, though, run across a light-hearted, but nonetheless cautionary article about nudging in the Toronto Globe and Mail: http://www.theglobeandmail.com/globe-debate/im-an-adult-stop-nudging-me/article20925672/

However, we have to take advantage of all the tools at our disposal. My mother’s manipulation was unsubtle and in my face; nudging is not. If we are going to be successful in stopping the steadily increasing tide of obesity, we need to revise expectations, and change what we accept as normal. We have to alter folkways and mores –in other words the rules that society uses to guide behavior. Nudge them, I suppose…

We need the courage to try novel approaches. There is a quote by Erasmus that is germane: A nail is driven out by another nail. Habit is overcome by habit. Okay, so let’s change them. Nudge them. No! I hate the verbal evasion. Let’s mold them.

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.