Friday, 8 February 2019

Risking Fat People’s Lives “For Their Health”

One of the ways in which diet culture harms, and can even kill, fat people is its perpetuation of the idea that a fat life is more risk-able than a thin life. The underlying belief of diet culture is that it’s better to be miserable, or even dead than to be fat.

We see this in lots of ways.

Medications being prescribed to fat people that risk our health and lives for a few pounds lost (and quickly regained.) 

Gruesome and barbaric recommendations, like pumping food out of our stomachs into a bucket, are seen as totally reasonable, without any regard for how they will affect our physical or mental health.

And of course there is the horror of stomach amputation and binding (aka “bariatric” or “weight loss” surgeries.):

A pretty clear example: a thin person and a fat person go to the same doctor. Both have elevated blood sugar. Their numbers are exactly the same. The thin person is prescribed medication with few side effects that is shown to help control blood sugar. The fat person is referred for a surgery during which most of their stomach will be amputated causing a risk of death on the table, short- and long-term death from complications, and horrible lifelong side effects. The fat person is asked to risk their life and quality of life to control blood sugar. The thin person is asked to take medication.

The same thing happens when a fat person who actually needs knee surgery is told that they can’t get it because knee surgery is too dangerous, and then they are given the recommendation to have stomach amputation surgery, which is far more dangerous with far worse possible side-effects.

Sadly this isn’t limited to adults, in Australia the “Fast Track to Health” study will literally starve children, despite the fact that the evidence does not suggest that it will do anything to change their weight, there are serious questions about severe food restriction during children’s growth years, and the study perpetrators know that they are risking inducing eating disorders. (There is a fantastic take-down of this here.)

I’m writing about this because I think it’s important to realize that when we are advocating for our health and healthcare, we are often advocating against a system that thinks that it’s worth killing us, or ruining our lives, to make us thin – no matter what we think.

Fat people have the right to exist, in fat bodies, and it doesn’t matter why we’re fat, what the “consequences” of being fat might be, or if we could (or want to) become thin. Fat people have the right to healthcare that supports our actual bodies, rather than insisting that we risk our lives to be thin before we are treated as human beings, worthy of appropriate, evidence-based healthcare

Nobody knows what fat people’s health outcomes would look like if we lived in a society that celebrated the diversity of body sizes, gave us the opportunity to love our bodies and see them as worthy of care, and the access to take good care of them. I’d like to find out

Was this post helpful? If you appreciate the work that I do, you can support my ability to do more of it with a one-time tip or by becoming a member. (Members get special deals on fat-positive stuff, a monthly e-mail keeping them up to date on the work their membership supports, and the ability to ask me questions that I answer in a members-only monthly Q&A Video!)

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Non-Members click here for all the details and to register!

Book and Dance Class Sale!  I’m on a journey to complete an IRONMAN triathlon, and I’m having a sale on all my books, DVDs, and digital downloads to help pay for it. You get books and dance classes, I get spandex clothes and bike parts. Everybody wins! If you want, you can check it out here!  (Members get an even better deal, make sure to make your purchases from the Members Page!)

Book Me!  I’d love to speak to your organization. You can get more information here or just e-mail me at ragen at danceswithfat dot org!

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Wednesday, 6 February 2019

Salad-Eating Fatphobe on Plane Gets Just Desserts

Pink Background, a black and white image of thin woman in a dress and heels leans on a table and waving. Black text says "Wait, Come back. You forgot your bullshit." someecards user cardOk, let me start by apologizing for that title, I just couldn’t help myself. Now on to the good news.

A fatphobe found herself seated in the middle seat on a plane between two plus-size people, and decided that her best choice was to verbally abuse her row-mates. She started on the phone to someone, complaining loudly that they were “squishing her” (though a video taken by Norma Rodgers, one of her row-mates does not substantiate that claim) Fatphobe then turned her ire to the flight attendant saying ““Get me out of here. I can’t do this. I can’t breathe, I’m so squished,” she said, before adding, “I eat salads, okay?”

Throughout the interaction we see the cruelty of fatphobia, but here we see the ridiculousness. Seriously, Fatphobe? “I eat salad.”? That’s what you went with?  Plenty of fat people eat salad, plenty of thin people don’t. Airlines have tons of promotions but “Eat a salad, choose your seatmates” is not one of them.

What isn’t funny at all is that she is white and her two row-mates are Black, so we have to ask ourselves to what extent racism was also at the root of, and driving her behavior.

At that point, in a bit of video that makes me want to stand up and cheer in my living room, Norma Rodgers – the hero we need – had e-fucking-nough and asked the flight attendant to find Fatphobe another seat because “I will not be abused by this bitch, or anybody else, I will not be verbally abused by anybody. I’m not tolerating it.” Tell her Ms. Rodgers.

The flight attendant asks Fatphobe to move to the back of the plane while they look for another seat and as she is leaving the row she says again “I eat salad.” That’s where it gets good.

While Ms. Rodgers asks the flight attendant how to report Fatphobe, repeating that she is not going to be treated this way, and the flight attendant empathizes and assists, the rest of the plane lets Fatphobe know that her behavior is not ok. In a glorious finish to this story, Fatphobe got kicked off the plane. I can only hope that her seat remained empty so that her abused row-mates could stretch out and enjoy their Fatphobe-free flight.

A few final points:

Much has been made in online discussions that I’ve seen about the fact that Fatphobe isn’t particularly thin. I don’t care about that, since there’s no weight at which her behavior would have been appropriate.

If you’re thinking something like “Making fat people buy two seats for one flight isn’t fat shaming, it’s just economics” then head over to this post.

If you’re thinking something like “But fat people on planes taking up space aren’t fair to thin people!” then head over to this post.

If you know what’s up, then just take this time to enjoy the fact that two fat people flew to their destinations while Fatphobe watched them take off from the airport, where flight attendants booted her ass after being shamed by fellow passengers of all sizes. Progress, far too slow and far too painful, but progress.

Did you like this post? If you appreciate the work that I do, you can support my ability to do more of it with a one-time tip or by becoming a member. (Members get special deals on fat-positive stuff, a monthly e-mail keeping them up to date on the work their membership supports, and the ability to ask me questions that I answer in a members-only monthly Q&A Video!)

Like this blog?  Here’s more cool stuff:

Wellness for All Bodies ProgramA simple, step-by-step, super efficient guide to setting and reaching your health goals from a weight-neutral perspective.  This program can be used by individuals, or by groups, including as a workplace wellness program!
Price: $25.00 ($10 for DancesWithFat members – register on the member page)

Non-Members click here for all the details and to register!

Book and Dance Class Sale!  I’m on a journey to complete an IRONMAN triathlon, and I’m having a sale on all my books, DVDs, and digital downloads to help pay for it. You get books and dance classes, I get spandex clothes and bike parts. Everybody wins! If you want, you can check it out here!  (Members get an even better deal, make sure to make your purchases from the Members Page!)

Book Me!  I’d love to speak to your organization. You can get more information here or just e-mail me at ragen at danceswithfat dot org!

I’m (still!) training for an IRONMAN! You can follow my journey at www.IronFat.com or on Instagram.

If you are uncomfortable with my offering things for sale on this site, you are invited to check out this post.



via Dances With Fat http://bit.ly/2RJjDLJ

Monday, 4 February 2019

VBAC and Prior Cervical Dilation


Some providers look for any excuse to discourage people from Vaginal Birth After Cesarean (VBAC). They might tell you that you're not a good candidate for VBAC because you are too old, too fat, too short, that you have to have your baby before your due date, that you've gained too much weight, and on and on.

One of the tools that is sometimes used to discourage VBAC is the prior dilation in the previous labor. Some have been told that if they dilated nearly all the way or even all the way to 10 cm, they have little or no chance at a VBAC. Others have been told the opposite, that if they didn't dilate very far previously, their chances of VBAC are low.

But what does the research actually say? 

Prior Dilation and VBAC

A New York study (Hoskins and Gomez 1997) was one of the first studies to look at prior dilation and its association with later VBAC. It found a much greater VBAC rate in those who had a c-section at lower dilation. The VBAC rate at later dilation was only 13%.

However, this is the only study I could find that had more VBACs in the group with less dilation. But because this 1997 study was the first one to really examine the question, its findings have stuck in many doctors' memories, despite contradictory studies, so you sometimes still hear this argument.

A small Nigerian study (Onifade and Omigbodun, 2003) found that prior dilation had no influence on later VBAC. They concluded, "the maximum cervical dilatation reached before primary caesarean section need not be factored into a decision for VBAC."

On the other hand, most studies have found that the greater your dilation in a previous labor, the better your chances at a subsequent VBAC.

One 2001 Canadian study found a higher VBAC rate (75%) among those whose cesareans occurred after dystocia in the second stage of labor/after full dilation. Do note, though, that the group where dystocia occurred in the first stage still had a 66% VBAC rate.

A Korean study (Kwon 2009) also found that those with greater prior dilation had more VBACs.

A Danish study (Abildgaard 2013) had a very low overall VBAC rate but even so found more VBACs in those with greater prior dilation. N=373 women had a Trial of Labor. Those with 4-8 cm dilation before their first cesarean had a 39% VBAC rate, whereas those who were fully or nearly fully dilated at cesarean had a 59% VBAC rate. 

And now, a new study (Lindblad Wollman 2018) also suggests that the chance of VBAC is increased with greater prior dilation. This was a large population-based cohort study in Sweden for 6 years from 2008-2014; such a large study gives its findings extra heft.  N=3,116 women with 1 prior cesarean had a Trial of Labor (TOL). 70% had a VBAC. In those who had a prior cesarean for dystocia:
... increasing cervical dilation in first labor decreased the risk of repeat cesarean in second labor. The adjusted RR of repeat cesarean was 2.48 with dilation ≤5 cm, 1.98 with dilation 6-10 cm, and 1.46 if fully dilated. 
CONCLUSIONS: Almost 70% of all women eligible for trial of labor after cesarean had a vaginal birth, even women with a history of labor dystocia had a good chance of success. A greater cervical dilation in the first delivery ending with a cesarean was not in vain, since the chance of vaginal birth in the subsequent delivery increased with greater dilation.
Overall, the research suggests pretty strongly that the more dilation you had previously, the better your likelihood for a VBAC later. Why might that be? Perhaps the key is how ripe the mother's cervix was before labor (a ripe cervix dilates more easily), and that once you've fully dilated once, you're likely to again.

What it doesn't mean is that someone who didn't dilate very far the first time is a bad candidate for a VBAC. As the Swedish study above points out, "even women with a history of labor dystocia had a good chance of success."

But really, in the end, who cares how many centimeters you dilated last time? The point is that with patience and a supportive provider, most people will have a VBAC, regardless of risk factors. That's all you really need to know.

Providers, Stop Looking for Excuses 



As the top graphic of this post points out, VBAC is woefully underused. About 90% of those with prior cesareans are eligible for a VBAC, yet only about 10% end up having one. Yes, some people choose repeat cesareans, and some people labor for a VBAC but end up with another cesarean. However, the biggest reason for the low number of VBACs is because VBAC has been strongly discouraged by many providers.

Some providers won't support VBAC at all. Others pretend to be supportive but place so many limitations on a trial of labor that almost no one gets a VBAC. Others limit trials of labor to only those with the MOST favorable risk factors.

Providers, stop making excuses. Don't use prior cervical dilation or past arrest disorder or gestational age or Body Mass Index or maternal age or any of a thousand other lame excuses to discourage people from a VBAC.

Arbitrarily limiting VBAC to those with only the most favorable factors makes the repeat cesarean rate far too high, results in far too many complications, and does more harm than good. Our skyrocketing rate of placental abnormalities, cesarean scar pregnancies, and maternal mortality rates reflect that.

Sure, certain factors may make a VBAC slightly more or less likely, but the stark truth is that the majority of those who labor will have a VBAC, even when there are less favorable risk factors.

Stop looking for excuses to not support VBAC. Stop the high-handed paternalism that peremptorily decides birthing choices for others. Stop infantalizing women and taking away their autonomy to make their own medical decisions. People should be counseled about the benefits and risks of each option, but in the end the final choice belongs to the mother.

Unless someone has a legitimate medical contraindication, stop discouraging people from pursuing a VBAC if they want one.


References

Acta Obstet Gynecol Scand. 2018 Dec;97(12):1524-1529. doi: 10.1111/aogs.13447. Epub 2018 Sep 25. Risk of repeat cesarean delivery in women undergoing trial of labor: A population-based cohort study. Lindblad Wollmann C, Ahlberg M, Saltvedt S, Johansson K, Elvander C, Stephansson O. PMID: 30132803
... We investigated the association between indication of first cesarean and cervical dilation during labor preceding the first cesarean and risk of repeat cesarean in women undergoing trial of labor. MATERIAL AND METHODS: A population-based cohort study using electronic medical records of all women delivering in the Stockholm-Gotland region, Sweden, between 2008 and 2014. The population consisted of 3116 women with a first cesarean undergoing a trial of labor with a singleton infant in cephalic presentation at ≥37 weeks of gestation... In women with a cesarean due to dystocia, increasing cervical dilation in first labor decreased the risk of repeat cesarean in second labor. The adjusted RR of repeat cesarean was 2.48 with dilation ≤5 cm, 1.98 with dilation 6-10 cm, and 1.46 if fully dilated. CONCLUSIONS: Almost 70% of all women eligible for trial of labor after cesarean had a vaginal birth, even women with a history of labor dystocia had a good chance of success. A greater cervical dilation in the first delivery ending with a cesarean was not in vain, since the chance of vaginal birth in the subsequent delivery increased with greater dilation.
Acta Obstet Gynecol Scand. 2013 Feb;92(2):193-7. doi: 10.1111/aogs.12023. Epub 2012 Nov 5. Cervical dilation at the time of cesarean section for dystocia -- effect on subsequent trial of labor. Abildgaard H, Ingerslev MD, Nickelsen C, Secher NJ. PMID: 23025257
... DESIGN: Retrospective study. SETTING: University hospital in Copenhagen capital area. POPULATION: All women with a prior cesarean section due to dystocia who had undergone a subsequent pregnancy with a singleton delivery during 2006-2010. METHODS: Medical records were reviewed for prior vaginal birth, cervical dilation reached before cesarean section and induction of labor, gestational age, use of oxytocin, epidural anesthesia and mode of birth was collected. RESULTS: A total of 889 women were included; 373 had had a trial of labor. The success rate for vaginal birth among women with prior cesarean section for dystocia at 4-8 cm dilation was 39%, but 59% for women in whom prior cesarean section had been done at a fully or almost fully dilated cervix (9-10 cm) (p < 0.001). Among the women with a previous vaginal delivery prior to their cesarean section, the success rate for vaginal birth was 76.2%, in contrast to 48.9% in the group without a previous vaginal delivery (p < 0.01). CONCLUSION: Women who had a trial of labor after a prior cesarean section for dystocia done late in labor and women with a vaginal delivery prior to their cesarean section had a greater chance of a successful vaginal birth during a subsequent delivery.
J Matern Fetal Neonatal Med. 2009 Nov;22(11):1057-62. doi: 10.3109/14767050902874089. Cervical dilatation at the time of cesarean section may affect the success of a subsequent vaginal delivery. Kwon JY, Jo YS, Lee GS, Kim SJ, Shin JC, Lee Y. PMID: 19900044
... The medical records of women attempting VBAC between January 2000 and February 2008 were reviewed. All women had only one previous cesarean and underwent spontaneous labor. RESULTS: Among 1148 enrolled women, 956 (83.3%) achieved a successful VBAC. Birth weight, previous indication for cesarean delivery and oxytocin augmentation were significantly associated with VBAC outcome. By multivariate analysis, a cervical dilatation >or=8 cm at previous cesarean was independently predictive of successful VBAC in women with a previous cesarean for non-recurrent indications (p = 0.046), yielding a VBAC success rate of 93.1%, whereas the extent of cervical dilatation at the previous cesarean did not affect the outcome of subsequent delivery in women with a previous cesarean for recurrent indications. CONCLUSIONS: Women with cesarean for non-recurrent indications who achieved a cervical dilatation >or=8 cm may be the best candidates for VBAC, with the greatest likelihood of a successful VBAC. Labor progress at previous cesarean can serve as a valuable indicator for VBAC outcome in women with a previous cesarean for non-recurrent indications, and therefore should be discussed as part of preconception counseling.
Obstet Gynecol. 1997 Apr;89(4):591-3. Correlation between maximum cervical dilatation at cesarean  delivery and subsequent vaginal birth after cesarean delivery. Hoskins IA, Gomez JL. PMID: 9083318
... Relevant records of the index pregnancy (group I) were reviewed for cervical dilatation at cesarean delivery, oxytocin use, indication, neonatal weight, and epidural use. The records of the subsequent pregnancy (group II) were reviewed for successful VBAC rates, neonatal weight, oxytocin, and epidural use. RESULTS: There were 1917 patients in the study. The indications for cesarean in group I were ... arrest disorders (80%)... In those with previous cesarean deliveries for arrest disorders with cervical dilatation at 5 cm or less, the VBAC success rate was 67%. It was 73% for 6-9 cm dilatation and 13% for the fully dilated group (P < .05). CONCLUSIONS: Patients who attempt a VBAC may be counseled that a cesarean delivery at full dilatation is associated with a reduced chance of a subsequent successful VBAC.
AJP Rep. 2017 Jan;7(1):e31-e38. doi: 10.1055/s-0037-1599129. Validation of a Prediction Model for Vaginal Birth after Cesarean Delivery Reveals Unexpected Success in a Diverse American Population. Maykin MM, Mularz AJ, Lee LK, Valderramos SG. PMID: 28255520 Full free text here.
OBJECTIVE: To investigate the validity of a prediction model for success of vaginal birth after cesarean delivery (VBAC) in an ethnically diverse population. METHODS: We performed a retrospective cohort study of women admitted at a single academic institution for a trial of labor after cesarean from May 2007 to January 2015. Individual predicted success rates were calculated using the Maternal-Fetal Medicine Units Network prediction model. Participants were stratified into three probability-of-success groups: low (<35%), moderate (35-65%), and high (>65%). The actual versus predicted success rates were compared. RESULTS: In total, 568 women met inclusion criteria. Successful VBAC occurred in 402 (71%), compared with a predicted success rate of 66% (p = 0.016). Actual VBAC success rates were higher than predicted by the model in the low (57 vs. 29%; p < 0.001) and moderate (61 vs. 52%; p = 0.003) groups. In the high probability group, the observed and predicted VBAC rates were the same (79%). CONCLUSION: When the predicted success rate was above 65%, the model was highly accurate. In contrast, for women with predicted success rates <35%, actual VBAC rates were nearly twofold higher in our population, suggesting that they should not be discouraged by a low prediction score.
Other So-Called "Risk Factors" for Failed VBAC


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Sunday, 3 February 2019

The Super Bowl, Fat People, Prioritizing Health, and Hypocrisy

Super BowlOne of the reasons most commonly given for refusing to treat fat people with basic human respect, or to represent fat people in the media as happy, or successful at anything other than weight loss, is that fat people aren’t “prioritizing our health” and thus deserve to be treated poorly and denied positive media representation.

For today I’m setting aside the fact that this is both completely untrue and that it even if it was true it would still be extremely messed up, to discuss the almost unbelievable hypocrisy that is committed anytime this argument is made and, specifically, on Super Bowl Sunday, in this annual DWF post.

Today Super Bowl LIII will be played (for those not into sportsball, it’s the annual championship game of United States Football.) It has an anticipated audience of over 100 million people. Advertisers paid $5.25 Millon for a 3o second spot.

The dudes who will play in the game – many of them meeting the (totally bullshit) definition of “obese” – will be putting their short and long term health in jeopardy in the hopes of scoring more points than some other dudes, and winning jewelry.

If we really believe that people who don’t prioritize their health should be treated poorly and denied positive media representation, then I’m pretty confused here:

First is this incredibly long list of injuries.

And what about the massive impact of concussions on players future lives (and the NFL cover-up thereof.)

Or the fact that the rate of bankruptcy means that taxpayers will likely pick up the cost of most of the future healthcare they’ll need.

Football players are given massive media exposure despite the fact that they are clearly not prioritizing their own health.

So if we think that people who don’t “prioritize their health” are poor role models and shouldn’t be represented positively in the media, what is this whole Superbowl thing about?  Where is the insistence that football players aren’t good role models because they aren’t prioritizing their health? Where are the calculations about how expensive football players (from Pop Warner to Pro) will be – not just with sports injuries while they play, but with the fallout from concussions, and the constant pounding their joints take? Where is the WON’T SOMEBODY THINK OF THEIR KNEES hand-wringing?

Where are the calculations of how much money could be saved if instead of playing football those who participate just walked 30 minutes a day 5 days a week?  Where’s the government-sponsored “War on Football Playing”? And all of that despite the fact that body size is complicated and not entirely within our control and we don’t have a single study where more than a tiny fraction of people were able to change their body size, but playing (or not quitting) football is absolutely a choice.

To be clear, people are allowed to play football. My point here is that this whole “It’s because of fat people’s health that we treat them badly” thing is just a crappy justification for size-based discrimination, and it’s long past time to stop using healthism and ableism to justify sizeism, and to end all of them instead.

Did you like this post? If you appreciate the work that I do, you can support my ability to do more of it with a one-time tip or by becoming a member. (Members get special deals on fat-positive stuff from myself and other cool businesses, a monthly e-mail keeping them up to date on the work their membership supports, and the ability to ask me questions that I answer in a members-only monthly Q&A Video!)

Like this blog?  Here’s more cool stuff:

Wellness for All Bodies ProgramA simple, step-by-step, super efficient guide to setting and reaching your health goals from a weight-neutral perspective.  This program can be used by individuals, or by groups, including as a workplace wellness program!
Price: $25.00 ($10 for DancesWithFat members – register on the member page)

Non-Members click here for all the details and to register!

Book and Dance Class Sale!  I’m on a journey to complete an IRONMAN triathlon, and I’m having a sale on all my books, DVDs, and digital downloads to help pay for it. You get books and dance classes, I get spandex clothes and bike parts. Everybody wins! If you want, you can check it out here!  (Members get an even better deal, make sure to make your purchases from the Members Page!)

Book Me!  I’d love to speak to your organization. You can get more information here or just e-mail me at ragen at danceswithfat dot org!

I’m (still!) training for an IRONMAN! You can follow my journey at www.IronFat.com or on Instagram.

If you are uncomfortable with my offering things for sale on this site, you are invited to check out this post.



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Friday, 1 February 2019

Photoshoot Friday – My Fat Positive Session with Lindley Ashline

Ok, let’s start here: Photoshoot Friday isn’t so much an actual thing as an excuse for using alliteration. Which is to say it won’t be an every Friday kind of thing. The name just popped into my head and I couldn’t let go of the alliteration (regular readers readily remember that I’m always all about alliteration.) Photoshoots are pretty far out of my comfort zone, so when Lindley Ashline offered to do this shoot while I was in Oregon, I decided it was a face your fears kind of thing – especially since her commitment to fat positivity made it far less scary.

Lindley is the photographer behind Sweet Amaranth: Body Positive Boudoir & Portrait Photography and she is also the person behind the Body Love Box, a fat positive and intersectional monthly subscription box.

We did three locations around Portland. The pictures in the red dress are taken at the Rhododendron Garden. It was beautiful and freezing cold (for an LA by way of Austin girl – it turns out that the cold weather tolerance I developed in my youth is looooong gone!)

In addition to giving me posing tips (I have talents, but modeling is not one of them) and creating a delightful air of fat positivity around the whole shoot, Lindley would tell me what parts of me weren’t in the shot and let me cover them with a coat – she’s the best!

The pictures of me walking and running are also in the Rhododendron Garden and running around, not to mention wearing pants, helped me keep warmer. Normally I’m not a big proponent of pants but in this case… A million bonus points to Lindley since she was working in those conditions.

Lindley then drove out to the ruins of a stone house. My experience of Portland was that you can fall off any curb and into the woods – there are trees EVERYWHERE. This was no exception – a stunningly beautiful location that was just a few feet off the highway. Though I will say that those feet were straight up a muddy embankment with me lugging my suitcase full of various outfits and other photoshoot detritus, and Lindley having to haul all of her stuff up as well. It was totally worth it and we had fun playing with the existing “furniture” at the site, as well as Lindley’s fabulous blue sequin fabric.

We finished with a little scale smashing in my Fatties Against Fascism Shirt (get your own here!) I’ll let you in on a little secret – because we were on a public street and we didn’t have the supplies we needed to clean it up properly, we didn’t actually smash the scale.

It was an incredible day, working with Lindley was a joy, and I’m thrilled with the pictures. (You can click on them to enlarge if you would like.) Pictures are not authorized for use without express permission. If you’d like permission to utilize the photos, e-mail me at ragen@danceswithfat.org

A million thank yous to Lindley, who is a true professional and a joy to work with! You can find her, and her fab pictures, in all of these places:

Instagram: @sweetamaranth

Twitter: @sweetamaranthus

http://www.sweetamaranth.com

Representation Matters  – Diverse Stock Photos

Disclosures for Transparency:

Lindley gifted the photoshoot to me (Thank you!)  I don’t get compensated for linking to her work, or for any purchases made from her.

Junonia gave me the red shirt from the walk/run photos as part of a campaign that they are working on, these pictures may become part of that campaign. Other than the shirt, I won’t be compensated for the campaign, and I don’t get compensated for linking to their site, or for any purchases made there.

I’m not affiliated with the makers of the Fatties Against Fascism shirts (other than loving their work) I paid full price for my shirts from them, and don’t get compensated for linking to their site, or for any purchases made there.

Like this blog?  Here’s more cool stuff:

Wellness for All Bodies ProgramA simple, step-by-step, super efficient guide to setting and reaching your health goals from a weight-neutral perspective.  This program can be used by individuals, or by groups, including as a workplace wellness program!
Price: $25.00 ($10 for DancesWithFat members – register on the member page)

Non-Members click here for all the details and to register!

Book and Dance Class Sale!  I’m on a journey to complete an IRONMAN triathlon, and I’m having a sale on all my books, DVDs, and digital downloads to help pay for it. You get books and dance classes, I get spandex clothes and bike parts. Everybody wins! If you want, you can check it out here!

Book Me!  I’d love to speak to your organization. You can get more information here or just e-mail me at ragen at danceswithfat dot org!

I’m (still!) training for an IRONMAN! You can follow my journey at www.IronFat.com or on Instagram.

If you are uncomfortable with my offering things for sale on this site, you are invited to check out this post.

 



via Dances With Fat http://bit.ly/2HMacLT

Tuesday, 22 January 2019

Metformin Use in Nondiabetic Obese Pregnancy

Article from The Daily Mail, 2011

One of the strongest concerns doctors have about pregnancies in the "obese" is that larger people tend to have larger (macrosomic) babies. Although most macrosomic babies are born just fine, they do have higher rates of shoulder dystocia (babies who get stuck) and related injuries, as well as low blood sugar at birth and more cesareans. So doctors want to do everything they can to prevent abnormally big babies.

Some macrosomia is tied to high blood sugar and high insulin levels. So in hopes of preventing big babies, doctors have been using the diabetes medication, metformin, in those diagnosed with Gestational Diabetes (GD) or Polcystic Ovarian Syndrome (PCOS).

A number of studies have confirmed that metformin use in women with GD does modestly reduce the rate of big babies. It also lowers the rate of early pregnancy loss and prematurity in PCOS. More research is needed but metformin does seem to be a very helpful drug for people with GD or PCOS. No one is questioning this use of metformin.

However, the use of metformin in obese women WITHOUT gestational diabetes or PCOS is a different story. Doctors note that even high BMI people who are not diabetic have larger babies on average. So the working theory has been that these women must be pre-diabetic or have strong insulin resistance that increases fetal size.

So doctors began prescribing metformin to nondiabetic obese women in hopes that lowering insulin levels and borderline blood sugar would cut the odds of a big baby.

The practice was aggressively marketed to the public as a way to prevent "obese babies" before its research was even completed (see headlines quoted here from The Daily Mail 2011 and 2012).

But what does the research say about this use of metformin? Here is a quick summary of the three largest trials.

The Studies on Non-Diabetic High BMI Women

From article in the Daily Mail, 2012
Chiswick 2015

Several years ago, a large study called the EMPOWaR trial (Chiswick 2015) tested this theory in the U.K.

This study involved 15 hospitals and was a large, randomized, double-blind placebo-controlled trial, the gold standard of research. It had n=434 participants with a BMI over 30 for analysis. The maximum metformin dose was 2500 mg.

To authors' great surprise, they found that metformin did NOT lower neonatal size.

Syngelaki 2016

Some common criticisms of the EMPOWaR study were that the metformin dose was too low, the participants weren't fat enough to show any big effect, and they did not take doses strictly enough.

Therefore, in a subsequent study published in the prestigious New England Journal of Medicine (Syngelaki 2016, the MOP trial), n=400 participants were limited to those with a BMI over 35. This study, too, was a randomized, double-blind study with placebo controls and was more racially diverse.

The researchers increased the metformin dose to a maximum of 3000 mg and made sure there was strong adherence to the medication. By limiting the analysis to those with a BMI over 35, increasing the dosage, including more women of color, and making sure metformin was consistently used, the authors hoped to show more of an effect.

To their surprise, results were again similar. While the metformin group had a slightly lower weight gain, fetal size was the same between groups.

Dodd 2019

Researchers just can't leave this theory alone.

Now there is a new study (the GRoW trial) out, also testing the metformin theory (Dodd 2019). This trial was done in Australia and included women with a BMI over 25 (in other words, both "overweight" and "obese"). No previous study had included those in the overweight category.

This also was a gold standard randomized study, n=514 participants. It used doses of up to 2000 mg.

It also found slightly less weight gain in the metformin group but NO difference in birthweight of the babies.

Research Summary

There have been a few other, small studies about metformin use in nondiabetic women, but none have been as large or as strong as these studies. No study so far has found that metformin lowers neonatal birthweight in nondiabetic women. That message is very clear and consistent.

There were other outcomes that weren't as clear. Some, but not all, studies found a mild lowering of prenatal weight gain. Some found decreased incidence of preeclampsia, while others did not. No other outcomes were routinely affected.

At this point, the hypothesis that metformin will "normalize" the size of high BMI women's babies has pretty well been disproven. I'm sure there will be more studies on it because the theory is a favorite of many OBs, but these are strong studies and frankly, I doubt they'll be overturned.

The good news is that no babies seem to have been harmed in these studies. However, many of the mothers experienced significant gastrointestinal side effects from the metformin and this some caused drop-outs or scaled-back dosing. If you've ever taken metformin, you know the G.I. effects can be considerable. This certainly affects people's quality of life. As a result, it's not something that should be prescribed lightly.

The take-home message from research: Metformin is a great drug that can be useful for some indications (like GD or PCOS) but in nondiabetic high BMI women it does not lower neonatal birthweight. As the authors of the EMPOWaR study concluded:
... metformin should not be used to improve pregnancy outcomes in obese women without diabetes.
The Fat-Shaming Around These Studies

Illustration from the 2012 Daily Mail article
It has to be pointed out that the U.K. public health campaign around these studies was glaringly fat-shaming.

Look at the caption above. Fat women are accused of letting their babies be "born obese," of passing on their toxic obesity in the womb through their carelessness about their health. They use the classic picture of a fat body with the head cut off, depersonalizing the subject. The person is even holding a roll of fat, pointing out visual blame so the negative message is even clearer. 

The articles were filled with scary summaries of the risks of obesity and pregnancy, without any context for those risks, how often they don't happen, and what can be done about them when they do. It's not unreasonable to inform women of size of the possible risks around weight and pregnancy, but it's another thing to misrepresent those risks to scare or shame women out of pregnancy.

The campaign was attempting to inflame the public about irresponsible fat people, implying that they refuse to be healthy and are costing the NHS huge amounts of money, taking money away from everyone else. The U.K. is a very fat-phobic place and the government is scapegoating fat people for their healthcare budget woes.

The language of the campaign was also offensive. They used the terms "fat babies" or "obese babies" in order to shame the mothers, but a big baby is not necessarily the same as an "obese" baby. They are conflating fetal size caused by diabetic complications with big babies that are simply larger than average.

All big babies are not alike. Some babies are big because of blood sugar issues, and these babies do tend to be abnormally proportioned and have more issues at birth. On the other hand, some babies are just naturally larger without it being pathological. There is a significant difference between a diabetic's baby that is 9 lbs. but only 16 inches long and a 9 lb. baby that is 22 inches long. The first is abnormal and a true concern; the second is proportional and most likely genetic. The first type often has problems being born safely and has many complications; the second type of big baby is proportional and can usually be born vaginally.

Furthermore, the campaign is simplistic and misleading. Not all obese mothers have macrosomic babies; one study found that only 17% of obese women had macrosomic babies while 83% of them did NOT. Subjecting all obese women to metformin "just in case" means medicating many people who wouldn't produce a big baby anyhow. What potential harm might that be doing?

Some people of average size also have macrosomic babies without blood sugar or insulin issues; no one knows why some babies are bigger than others. And many big babies do have vaginal births; Navti 2007 found that 83% of women who had babies around 10 pounds or more were able to have vaginal births. This shows that even very big babies can often be born vaginally, given time, patience, sufficient mobility, and a calm caregiver. We need to stop panicking over babies that are larger than average and save our intervention for those who truly need it.

Researchers: Stop trying to put the baby on a diet before it is even born. Metformin for reducing fetal size does not work in nondiabetics. 

Public Health Campaigns: Stop promoting weight stigma and fat-shaming in your campaigns about obesity and pregnancy. 



References

Lancet Diabetes Endocrinol. 2019 Jan;7(1):15-24. doi: 10.1016/S2213-8587(18)30310-3. Epub 2018 Dec 4. Effect of metformin in addition to dietary and lifestyle advice for pregnant women who are overweight or obese: the GRoW randomised, double-blind, placebo-controlled trial. Dodd JM, Louise J, Deussen AR, Grivell RM, Dekker G, McPhee AJ, Hague W.  PMID: 30528218
... GRoW was a multicentre, randomised, double-blind, placebo-controlled trial in which pregnant women at 10-20 weeks' gestation with a BMI of 25 kg/m2 or higher were recruited from three public maternity units in Adelaide, SA, Australia. Women were randomly assigned (1:1) via a computer-generated schedule to receive either metformin (to a maximum dose of 2000 mg per day) or matching placebo. Participants, their antenatal care providers, and research staff (including outcome assessors) were masked to treatment allocation...  FINDINGS: Of 524 women who were randomly assigned between May, 28 2013 and April 26, 2016, 514 were included in outcome analyses (256 in the metformin group and 258 in the placebo group). Median gestational age at trial entry was 16·29 weeks (IQR 14·43-18·00) and median BMI was 32·32 kg/m2 (28·90-37·10); 167 (32%) participants were overweight and 347 (68%) were obese. There was no significant difference in the proportion of infants with birthweight greater than 4000 g (40 [16%] with metformin vs 37 [14%] with placebo; adjusted risk ratio [aRR] 0·97, 95% CI 0·65 to 1·47; p=0·899). Women receiving metformin had lower average weekly gestational weight gain (adjusted mean difference -0·08 kg, 95% CI -0·14 to -0·02; p=0·007) and were more likely to have gestational weight gain below recommendations (aRR 1·46, 95% CI 1·10 to 1·94; p=0·008). ... INTERPRETATION: For pregnant women who are overweight or obese, metformin given in addition to dietary and lifestyle advice initiated at 10-20 weeks' gestation does not improve pregnancy and birth outcomes.
N Engl J Med. 2016 Feb 4;374(5):434-43.doi: 10.1056/NEJMoa1509819. Metformin versus Placebo in Obese Pregnant Women without Diabetes Mellitus. Syngelaki A, Nicolaides KH, Balani J, Hyer S, Akolekar R, Kotecha R, Pastides A, Shehata H. PMID: 26840133
[kmom summary] Randomized double-blind, placebo controlled trial. Limited to those with BMI over 35 and upped the metformin dosage. Less preeclampsia and less weight gain in metformin group but no difference in birth weight. "CONCLUSIONS: Among women without diabetes who had a BMI of more than 35, the antenatal administration of metformin reduced maternal weight gain but not neonatal birth weight."
Lancet Diabetes Endocrinol. 2015 Oct;3(10):778-86. doi: 10.1016/S2213-8587(15)00219-3. Epub 2015 Jul 9. Effect of metformin on maternal and fetal outcomes in obese pregnant women (EMPOWaR): a randomised, double-blind, placebo-controlled trial. Chiswick C, Reynolds RM, Denison F, Drake AJ, Forbes S, Newby DE, Walker BR, Quenby S, Wray S, Weeks A, Lashen H, Rodriguez A, Murray G, Whyte S, Norman JE. PMID: 26165398 Free full text here.
[kmom summary] Randomized placebo-controlled, double-blind study in 15 hospitals in the U.K. on nondiabetic women. Results: "Metformin has no significant effect on birthweight percentile in obese pregnant women."
Previous discussion of these studies and others:
Metformin for Gestational Diabetes or PCOS

J Matern Fetal Neonatal Med. 2018 Nov 20:1-141. doi: 10.1080/14767058.2018.1550480. [Epub ahead of print] Metformin-treated-GDM has lower risk of macrosomia compared to diet-treated GDM- A retrospective cohort study. Bashir M, Aboulfotouh M, Dabbous Z, Mokhtar M, Siddique M, Wahba R, Ibrahim A, Al-Houda Brich S, Konje JC, Abou-Samra AB. PMID: 30458653
...This is a retrospective cohort study that included GDM women compared to normoglycaemic controls between March 2015-December 2016 in the Women's Hospital, Qatar. RESULTS: The study included 2221 women; of which 1420 were normoglycaemic, and 801 were GDM (358 GDM-D and 443 GDM-T)... Women in the GDM-T group had lower GWG/week compared to GDM-D (-0.01 ± 0.7 versus 0.21 ± 0.51 kg/week; p < 0.001). After correcting for age, prepregnancy weight and GWG; GDM-T had higher risk of preterm labour (OR 1.66; 95% CI 1.20-2.22), and C-section (OR 1.37, 95% CI 1.02-1.85) and reduced risk of macrosomia (OR 0.56; 95% CI 0.32-0.96) and neonatal hypoglycaemia (OR 0.49; 95% CI 0.28-0.82). CONCLUSION: ... Treatment with metformin reduces maternal weight gain, the risk of macrosomia and neonatal hypoglycaemia compared to diet alone.
J Clin Endocrinol Metab. 2010 Dec;95(12):E448-55. doi: 10.1210/jc.2010-0853. Epub 2010 Oct 6. Metformin versus placebo from first trimester to delivery in polycystic ovary syndrome: a randomized, controlled multicenter study. Vanky E et al.  PMID: 20926533
[kmom summary] n=274 PCOS pregnancies. Randomized controlled trial with placebos. Less prematurity, but more pre-eclampsia in metformin group. Less weight gain in metformin group. No difference in fetal size between groups.  


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