Monday, 31 July 2017

Obesity and Joint Replacement, Part 2: Does Losing Weight First Improve Outcomes?


We have been discussing obesity and joint replacement operations, specifically knee replacements and hip replacements, and the common practice of denying these to people of size.

In Part One, we discussed the highly questionable ethics behind denying "obese" people joint replacement operations or requiring that they undergo weight loss counseling or bariatric surgery first. These practices keep many people of size from accessing joint replacements and improving their functional abilities and pain levels, sentencing many larger people to the difficulties of dealing with mobility challenges and a poorer quality of life.

Today, we discuss the data on whether losing weight before joint replacement actually improves long-term outcome, as so many doctors insist it will. Up till now it has been assumed that it will, but a closer look at longer-term research calls this assumption into question. Indeed, several recent studies that suggest that losing weight before knee replacement surgery does NOT improve outcome and might even result in worse outcomes.

Does Weight Loss Before Knee Replacement Help?

Of course, some readers will be asking, why not consider weight loss? If it will reduce the physical load on the joint and lessen pain and wear, why not pursue weight loss?

The answer is complicated.

It certainly seems logical that it would be advantageous to lose weight before an operation to replace a weight-bearing joint. There would be less weight and therefore less force on the joint, right?

And to be fair, there's definitely research that shows modest improvements in functionalityjoint force load, and pain levels with weight loss in patients with knee pain.

However, like most weight-loss research, these studies usually follow patients only short-term so the usual weight rebound effect is conveniently overlooked or minimized.

Even studies that promote weight loss for knee osteoarthritis admit (my emphasis):
Whether substantial weight loss can delay or even reverse the symptoms associated with osteoarthritis remains to be seen.
In other words, they do NOT have long-term proof that weight loss improves outcomes; they just assume it does because short-term studies (often just a few months) suggest some improvement.

This is the problem with nearly all weight-loss research; it only follows the patients long enough to show some benefits of a quick loss, but rarely follow patients long-term because many of the benefits are lost and most of the weight is regained (and often more), and doctors don't want to acknowledge that.

Even the usual recommendation to "lose just 5-10%" of a person's weight is problematic. While some research indicates modest benefits, research is actually quite limited on the long-term effects of such a loss. And most dieters do not manage or just barely manage that 5-10% weight loss over time.

Reviews of long-term research shows that for most people, few maintain the weight loss over time, most of the weight loss is regained with time, and many people rebound to higher weights or greater abdominal fat than they began with. There are biological reasons for this weight regain; it's not just about willpower.

Furthermore, weight loss can present risks as well as benefits, frequent weight fluctuation can be detrimental to health, and intentional weight loss/"dietary restraint" is one of the strongest predictors of long-term weight gain.

As a result, some care providers are now recommending that obese patients strive for weight stability rather than weight loss, and that the emphasis be placed on improving health habits and health measures instead of reducing a number on a scale.

Unfortunately, because short-term research shows modest improvements in joint function with weight loss, doctors have extrapolated this to assume that significant weight loss will improve long-term outcomes for joint replacement surgeries. As a result, some deny joint replacement to people above a certain BMI, practically mandate attendance at weight loss programs first, browbeat their patients about weight loss, or strongly push for bariatric surgery instead.

But does weight loss before joint replacement improve outcomes?

Weight Loss Before Joint Replacement 

In two recent new studies, the common assumption that having patients lose weight before having knee replacement surgery will automatically improve outcomes is questioned.

In a California study, only 12.4% of more than 10,000 knee replacement patients studied and 18% of more than 4000 hip replacement patients  managed to lose at least 5% of their starting weight in the year before their surgery. Around 75% of both groups stayed stable. Those who did manage to lose weight before knee replacement surgery did no better than those who did not lose weight before surgery. They had similar rates of surgical site infections and re-admissions for complications.

This certainly calls into question how helpful weight loss supposedly is before knee replacement.

In a companion study, those who lost weight before joint replacement surgery and managed to keep it off afterwards actually did worse than those whose weight stayed stable. The weight loss knee replacement group had more hospital re-admissions than those who did not lose weight. Furthermore, the hip replacement group who lost weight had more deep-site surgical infections. The authors noted:
These findings raise questions about the safety of weight management before total replacement of the hip and knee joints.
Why this increase in infections occurred is not clear. One theory is that when people are placed on a significantly low-calorie diet, nutrition can be impaired. It is difficult to get the proper amounts of all the nutrients when caloric intake is too low, and diets for these mobility-impaired people are often quite low-calorie because increasing exercise is difficult. As a result, some people with significant weight loss or chronic dieting histories develop nutrient deficiencies, and these may impair immune function. Research confirms that people with nutrient deficiencies have a greater risk for infections and other complications after joint surgery.

So while weight loss may reduce stress on the joint, nutrient deficiencies from this weight loss may affect immune function and ability to "bounce back" after surgery, negating any potential benefits of weight loss.

Furthermore, many people who lose substantial weight before joint replacements gain back that weight and more after the surgery. The end result of weight loss before joint replacement may be that the patient ends up weighing MORE later on, as one study found:
A patient with [hip replacement] had increased risk of important post-surgical weight gain of 12% (OR = 1.12, 95% CI, 1.08, 1.16) for every kilogram of pre-operative weight loss...Patients less than 60 years and who have lost a substantial amount of weight prior to surgery appear to be at particularly high risk of important post-surgical weight gain.
Ironically, requiring or strongly encouraging patients to lose a substantial amount of weight prior to joint replacement may backfire and ultimately add to the patient's weight, not lessen it. Yet most doctors continue to demand weight loss before joint replacement. Only now the emphasis is on weight loss via bariatric surgery instead.

Quote from Ragen Chastain, found here.

What About Bariatric Surgery First?

Because bariatric surgery is one of the only ways to lose weight in the long term (though it comes with many other complications and ususally involves some weight regain), many orthopedic surgeons are forming de-facto partnerships with bariatric surgeons.

As a result, many people of size are effectively blackmailed into weight loss surgery by BMI restrictions on joint replacements. 

One study from the Mayo Clinic states, "Morbidly obese individuals with severe degenerative joint disease who are considered unsuitable for arthroplasty because of excess weight should be considered for bariatric surgery."

Another surgeon reports that he accepts patients for knee replacements up to a BMI of 50, but after that he refers them for bariatric surgery first. (Because it makes SO much sense for someone too "at-risk" for one type of surgery to undergo a different type of surgery instead.)

Yet the common assumption that bariatric surgery should be promoted because it would surely improve outcomes in "morbidly obese" patients with significant osteoarthritis should also be questioned.

Some research does indicate improved outcomes in those who had bariatric surgery before joint replacement. And one recent study that looked only at short-term (90 days!) complications found lower rates of complications in those who had had bariatric surgery. Of course, the media was all over this study and it has been widely cited to justify requiring weight loss surgery.

However, other research does not support better outcomes with bariatric surgery, yet the press conveniently ignores that. In one study, complications were actually higher in the group with recent bariatric surgery (less than 2 years). The authors concluded:
Bariatric surgery prior to TJA [Total Joint Arthroplasty] may not provide dramatic improvements in post-operative TJA surgical outcomes. 
In another study from a major research hospital, researchers found an increased rate of joint replacements in bariatric patients who had experienced large or very rapid weight loss. They noted, "These results contradict the tenant that weight loss is universally protective against arthritis and merit larger prospective investigations."

Another recent study did not find improved outcomes in those who had had bariatric surgery before joint replacement. Indeed, many had worse outcomes instead, needing more revision surgeries afterwards.

This was echoed in a recent large retrospective cohort study that found worse outcomes in the group that had bariatric surgery first, compared to high-BMI people who did not. The WLS group had more infection, pneumonia, blood clots, heart issues, revisions, and manipulations of the prosthetetic.

recent meta-analysis found no significant benefit from bariatric surgery before joint replacement. The authors concluded:
For most peri-operative outcomes, bariatric surgery prior to THA or TKA does not significantly reduce the complication rates or improve the clinical outcome. This study questions the previous belief that bariatric surgery prior to arthroplasty may improve the clinical outcomes for patients who are obese or morbidly obese.
It may be that the potential benefits of reducing the load on the joint via weight loss from bariatric surgery may be outweighed by the nutrient deficits that are so common after weight loss surgery, even non-restrictive procedures. It may also be that the stresses on the body from rapid weight loss cause long-term damage to the body's ability to repair itself.

While some bariatric surgery patients have good outcomes and health improvement from the WLS, others have terrible outcomes, with significant nutritional deficits (sometimes despite supplements) and physical health problems. Some even die from the surgery or its after-effects. The problem is that you don't know which outcome group you are going to be in until after you've had the surgery. To strongly pressure joint replacement patients into bariatric surgery first means doctors are engaging in a high-stakes gamble with their patients' lives and quality of life.

And if joint replacement surgery at larger sizes is "too dangerous," why isn't weight loss surgery at larger sizes also too risky? Funny how patients are too fat for one surgery but surgeons can't wait to usher them into the Operating Room for WLS.

There are good reasons to question the common recommendation to have bariatric surgery before joint replacement. WLS is dangerous in and of itself, it often results in significant long-term nutrient deficits and other health problems, and it may not improve long-term outcomes for joint replacement.

However, as always, every person gets to make their own health decisions. Some people choose to have bariatric surgery before joint replacement and they have the right to do that. Others choose not to, and they also should have the right to do that. It's a choice with many pros and cons but one that should not be forced upon someone, which many doctors are essentially doing by denying joint replacement without bariatric surgery first.

In the past, care providers rarely studied whether or not bariatric surgery actually improved outcomes; they just assumed it will because it seems logical. But recent research shows there is good reason to question whether bariatric surgery really improves long-term outcome after all.

Mitigating Risk Through Better Management

Critics will no doubt point out that the risk for blood clots and post-operative infection are higher in obese patients and this is why they are concerned about operating on this group. This is true, and obese patients should be counseled about this fact. For example, one study found 6.7x the risk for infection in obese knee replacement patients, and 4.2x the risk for infection in obese hip replacement patients. The risk for infection is particularly strong among diabetics with a BMI over 40.

However, remember the dangers of using relative risk to discuss risk/benefit ratios; it can distort one's perception of risk. It is more helpful to use absolute numerical values so the magnitude of risks patients are assuming is more clear. One very large British study found that for knee replacements, risk for blood clots was increased from 2.0% to 3.3% and risk for infection from 3.0% to 4.1%, in obese patients with total knee replacements. For hip replacements, the risk for blood clots was increased from 2.2% to 3.3% and the risk for infection from 1.6% to 3.5% in obese patients. The authors noted (my emphasis):
Whilst an increased risk of wound infection and DVT/PE was observed amongst obese patients, absolute risks remain low and no such association was observed for MI, stroke and mortality.
However, the most important thing to point out is that an increased infection and clotting risk may be at least partly due to mismanagement of obese patients. Re-examining and changing the management protocols of these patients may improve outcomes independent of weight loss. 

For example, research shows that obese patients are chronically under-dosed with many medications. This is particularly relevant in antibiotics for preventing and treating infections, and in thromboprophylaxis medications for preventing blood clots after surgery. In other words, the two biggest risks of surgery in high-BMI patients may actually be largely preventable.

Obese patients, especially "morbidly-obese" (BMI 40+) and "super-obese" (BMI 50+) patients, are at particular risk for infections and may require larger initial antibiotic dosesextended or more frequent dosing regimens, use of more than one type of antibiotic, and perhaps topical infusions of antibiotics during surgery. This may help reduce their increased risk for infection after joint replacement surgery.

One recent study on infection in obese joint replacement patients strongly raised this issue of antibiotic underdosing. The authors found that above 100 kg (~220 lbs.), the rate of infections rose strongly. They noted that most patients in the study, regardless of BMI, were treated with a uniform dose (1.5g) of pre-op antibiotics and speculated that an increased antibiotic dose would help lower the rate of infections in this group. They stated:
The link between obesity and infection may be explained by several factors, but under-dosing of antibiotics is probably the most important to consider.
They also noted that noted that research examining the question of proper antibiotic dosage for obese patients undergoing joint replacement surgery was lacking. The problem of underdosing antibiotics in obese patients has been acknowledged in obstetric and bariatric surgery for several years. Why is it only NOW being brought up in orthopedic surgery?

Underdosing issues go beyond antibiotics. Research suggests that many obese patients are under-dosed with anti-clotting agents like heparin. One study found that weight-adjusted dosing cut the rate of blood clots in obese patients after surgery from 2.0% to 0.54% without increasing the risk for bleeding. Another study found that an extended prophylaxis period of anti-clotting agents lowered the risk for clots significantly, also without increasing bleeding.

Other surgical management protocols for obese patient need review as well. Some research suggests that surgical drains, often placed prophylactically in obese patients, have no benefit or may actually do more harm than good. Although further research is needed, one research review suggested omitting routine surgical drains in obese patients during joint replacement surgery.

As noted previously, another very interesting set of recent studies suggests that "morbid obesity" is less important that serum albumin levels on major complications like mortality and infections in joint replacement surgery. Serum albumin levels are an indicator of liver and kidney function but can also indicate nutrition status; obese people may be more at risk for malnutrition because of chronic dieting, highly restrictive intakes, or malabsorptive procedures like gastric bypass. Improving joint replacement outcomes might need to focus on measuring and fixing albumin levels and other nutrient deficits before surgery.

Bottom line, if the real concern is preventing poor outcomes, then perhaps the best approach is not to deny all high-BMI patients access to this surgery, but rather to lower morbidity by improving care for them instead via:
  • Utilizing weight-based dosing more uniformly in antibiotics and blood clot prevention drugs 
  • Using extended, adjunctive or more frequent antibiotic dosing regimens 
  • Avoiding routine prophylactic surgical drains 
  • Screening for and optimizing albumin and other nutrient levels before surgery
Ironically, a lot of the research on improving surgical outcomes in very obese patients is only done with bariatric surgery. It is past time to improve outcomes in high-BMI people in other types of surgery as well, including joint replacement surgery, instead of having to just extrapolate from bariatric surgery studies.

We need to know through evidence-based trials what the best protocols are for obese people undergoing joint replacement surgery. And in order to do that, we need for people of size to actually be given access to this surgery.

Summary

Sadly, even today, many orthopedic surgeons refuse to do knee replacements or hip replacements on anyone with a BMI over 35 or over 40 (or sometimes less).  In many places in the U.K., for example, people with a BMI over 35 have been routinely denied joint replacements and other surgeries. Some even deny joint replacements to those with a BMI over 30.

They do this because surgery is more technically challenging in very heavy people and because they view obesity as a voluntary condition brought on by poor lifestyle choices. They feel that losing weight is mostly a matter of willpower and choices, despite plenty of evidence to the contrary, and they feel they are doing their patients a favor by making them lose weight.

Surgeons also justify BMI restrictions by pointing out the short-term risks associated with orthopedic surgery in high-BMI people. They suggest that higher complication rates and somewhat lower functional outcomes justify denying surgery to this group and/or requiring weight loss or even bariatric surgery before joint replacement.

However, other surgeons are questioning the ethics of denying joint replacement surgery to high-BMI patients. They note that even very fat patients usually have good long-term outcomes from the surgery.

They recognize that the tremendous improvement in mobilityquality of lifeknee function, and pain relief is worth the trade-off of a potentially increased risk for mild short-term morbidity. Many are willing to proceed with joint replacement surgery in high-BMI patients as long as they have been given informed consent about the benefits and risks.

It is reasonable to counsel obese patients about the potential risks of a higher weight before surgery, especially if they have co-morbidities like diabetes. However, the counseling should cover both risks and benefits. It should acknowledge that the magnitude of risk is relatively modest in most obese patients and that most have very good long-term results from both knee replacement surgery and hip replacement surgery.

Patients can also be counseled about the potential benefits of weight loss before joint replacement surgery, as long as the data used is realistic and the potential risks of weight loss are also covered. But weight loss should not be required in order to access such surgery because research is contradictory on whether this is helpful. Short-term research shows some benefits, but longer-term research shows little benefit and sometimes even harm. Furthermore, the risks of weight loss, yo-yo dieting, and bariatric surgery should not be overlooked. More research is needed, but requiring weight loss before surgery is certainly not evidence-based. The truth is that the evidence is mixed and the choice should be left to the patient.

Joint replacement surgery in very obese patients is technically harder and does carry risks. However, the magnitude of this risk is modest and the potential for improvement in quality of life is very strong. Restricting high-BMI people from joint replacement surgery or requiring them to lose weight in order to access this surgery is NOT justified or ethical.

Rather, the risks are a call to surgeons to further examine the long-overlooked issue of how they manage obese patients. Risks can most likely be mitigated by proper medication dosing and more optimal surgical management of high-BMI patients.

Instead of restricting joint replacement or requiring weight loss in high BMI patients, orthopedic surgeons should be focusing on how they can improve outcomes in this group through modifications to surgical management protocols.


References

General Information about Joint Replacement

Weight Loss Before Joint Replacement

Bone Joint J. 2014 May;96-B(5):629-35. doi: 10.1302/0301-620X.96B5.33136. The risk of surgical site infection and re-admission in obese patients undergoing total joint replacement who lose weight before surgery and keep it off post-operatively. Inacio MC, Kritz-Silverstein D, Raman R, Macera CA, Nichols JF, Shaffer RA, Fithian DC. PMID: 24788497
This study evaluated whether obese patients who lost weight before their total joint replacement and kept it off post-operatively were at lower risk of surgical site infection (SSI) and re-admission compared with those who remained the same weight. We reviewed 444 patients who underwent a total hip replacement and 937 with a total knee replacement who lost weight pre-operatively and sustained their weight loss after surgery. After adjustments, patients who lost weight before a total hip replacement and kept it off post-operatively had a 3.77 (95% confidence interval (CI) 1.59 to 8.95) greater likelihood of deep SSIs and those who lost weight before a total knee replacement had a 1.63 (95% CI 1.16 to 2.28) greater likelihood of re-admission compared with the reference group. These findings raise questions about the safety of weight management before total replacement of the hip and knee joints.
J Arthroplasty. 2014 Mar;29(3):458-64.e1. doi: 10.1016/j.arth.2013.07.030. Epub 2013 Sep 7. The impact of pre-operative weight loss on incidence of surgical site infection and readmission rates after total joint arthroplasty. Inacio MC, Kritz-Silverstein D, Raman R, Macera CA, Nichols JF, Shaffer RA, Fithian DC. PMID: 24018161
This study characterized a cohort of obese total hip arthroplasty (THA) and total knee arthroplasty (TKA) patients (1/1/2008-12/31/2010) and evaluated whether a clinically significant amount of pre-operative weight loss (5% decrease in body weight) is associated with a decreased risk of surgical site infections (SSI) and readmissions post-surgery. 10,718 TKAs and 4066 THAs were identified. During the one year pre-TKA 7.6% of patients gained weight, 12.4% lost weight, and 79.9% remained the same. In the one year pre-THA, 6.3% of patients gained weight, 18.0% lost weight, and 75.7% remained the same. In TKAs and THAs, after adjusting for covariates, the risk of SSI and readmission was not significantly different in the patients who gained or lost weight pre-operatively compared to those who remained the same.
Osteoarthritis Cartilage. 2013 Jan;21(1):35-43. doi: 10.1016/j.joca.2012.09.010. Epub 2012 Oct 6.
Clinically important body weight gain following total hip arthroplasty: a cohort study with 5-year follow-up. Riddle DL, Singh JA, Harmsen WS, Schleck CD, Lewallen DG. PMID: 23047011
...DESIGN: We used multi-variable logistic regression to compare data from one of the largest US-based THA registries to a population-based control sample from the same geographic region. We also identified factors that increased risk of clinically important weight gain specifically among persons undergoing THA. The outcome measure of interest was weight gain of ≥5% of body weight up to 5 years following surgery. RESULTS: ...A patient with THA had increased risk of important post-surgical weight gain of 12% (OR = 1.12, 95% CI, 1.08, 1.16) for every kilogram of pre-operative weight loss. CONCLUSIONS: While findings should be interpreted with caution because of missing follow-up weight data, patients with THA appear to be at increased risk of clinically important weight gain following surgery as compared to peers. Patients less than 60 years and who have lost a substantial amount of weight prior to surgery appear to be at particularly high risk of important post-surgical weight gain. 
Arthritis Care Res (Hoboken). 2013 May;65(5):669-77. doi: 10.1002/acr.21880. Clinically important body weight gain following knee arthroplasty: a five-year comparative cohort study. Riddle DL, Singh JA, Harmsen WS, Schleck CD, Lewallen DG. PMID: 23203539
...METHODS: We used one of the largest US-based knee arthroplasty registries and a population-based control sample from the same geographic region to determine whether knee arthroplasty increases the risk of clinically important weight gain of ≥5% of baseline body weight over a 5-year postoperative period. RESULTS: Of the persons in the knee arthroplasty sample, 30.0% gained ≥5% of baseline body weight 5 years following surgery as compared to 19.7% of the control sample. The multivariable-adjusted (age, sex, body mass index, education, comorbidity, and presurgical weight change) odds ratio (OR) was 1.6 (95% confidence interval [95% CI] 1.2-2.2) in persons with knee arthroplasty as compared to the control sample. Additional arthroplasty procedures during followup further increased the risk for weight gain (OR 2.1, 95% CI 1.4-3.1) relative to the control sample. Specifically, among patients with knee arthroplasty, younger patients and those who lost greater amounts of weight in the 5-year preoperative period were at greater risk for clinically important weight gain. CONCLUSION: Patients who undergo knee arthroplasty are at an increased risk of clinically important weight gain following surgery. The findings potentially have broad implications to multiple members of the health care team. Future research should develop weight loss/maintenance interventions particularly for younger patients who have lost a substantial amount of weight prior to surgery, as they are most at risk for substantial postsurgical weight gain.
Bariatric Surgery Before Joint Replacement 

Bone Joint J. 2015 Nov;97-B(11):1501-5. doi: 10.1302/0301-620X.97B11.36477. Bariatric surgery does not improve outcomes in patients undergoing primary total knee arthroplasty. Martin JR, Watts CD, Taunton MJ. PMID: 26530652
Bariatric surgery has been advocated as a means of reducing body mass index (BMI) and the risks associated with total knee arthroplasty (TKA). However, this has not been proved clinically. In order to determine the impact of bariatric surgery on the outcome of TKA, we identified a cohort of 91 TKAs that were performed in patients who had undergone bariatric surgery (bariatric cohort). These were matched with two separate cohorts of patients who had not undergone bariatric surgery. One was matched 1:1 with those with a higher pre-bariatric BMI (high BMI group), and the other was matched 1:2 based on those with a lower pre-TKA BMI (low BMI group). In the bariatric group, the mean BMI before bariatric surgery was 51.1 kg/m(2) (37 to 72), which improved to 37.3 kg/m(2) (24 to 59) at the time of TKA. Patients in the bariatric group had a higher risk of, and worse survival free of re-operation (hazard ratio (HR) 2.6; 95% confidence interval (CI) 1.2 to 6.2; p = 0.02) compared with the high BMI group. Furthermore, the bariatric group had a higher risk of, and worse survival free of re-operation (HR 2.4; 95% CI 1.2 to 3.3; p = 0.2) and revision (HR 2.2; 95% CI 1.1 to 6.5; p = 0.04) compared with the low BMI group. While bariatric surgery reduced the BMI in our patients, more analysis is needed before recommending bariatric surgery before TKA in obese patients.
J Arthroplasty. 2016 Sep;31(9 Suppl):207-11. doi: 10.1016/j.arth.2016.02.075. Epub 2016 Mar 15. Lingering Risk: Bariatric Surgery Before Total Knee Arthroplasty. Nickel BT, Klement MR, Penrose CT, Green CL, Seyler TM, Bolognesi MP. PMID: 27179771
...METHODS: A total of 39,014 patients were identified in a claim-based review of the entire Medicare database with International Classification of Diseases, Ninth Revision codes to identify patients in 3 groups. Patients who underwent BS before total knee arthroplasty (group I: 5914 experimental group) and 2 control groups that did not undergo BS but had either a body mass index >40 (group II: 6480 bariatric control) or <25 (group III: 26,616 normal weight control)...RESULTS: ...Medical and surgical complication incidences were greatest in group I including: 4.98% deep vein thrombosis; 5.31% pneumonia; 10.09% heart failure; and 2-year infection, revision, and manipulation rates of 5.8%, 7.38%, and 3.13%, respectively. These values were significant elevation compared to III and slightly greater than II. CONCLUSIONS: This study demonstrates that BS before total knee arthroplasty is associated with greater risk compared to both nonobese and obese patients. This is possibly due to a higher incidence of medical or psychiatric comorbidities determined in the Medicare BS patients, wound healing difficulties secondary to gastrointestinal malabsorption, malnourishment from prolonged catabolic state, rapid weight loss before surgery, and/or age.
Bone Joint J. 2016 Sep;98-B(9):1160-6. doi: 10.1302/0301-620X.98B9.38024. Does bariatric surgery prior to total hip or knee arthroplasty reduce post-operative complications and improve clinical outcomes for obese patients? Systematic review and meta-analysis. Smith TO, Aboelmagd T, Hing CB, MacGregor A. PMID: 27587514
AIMS: Our aim was to determine whether, based on the current literature, bariatric surgery prior to total hip (THA) or total knee arthroplasty (TKA) reduces the complication rates and improves the outcome following arthroplasty in obese patients. METHODS: A systematic literature search was undertaken of published and unpublished databases on the 5 November 2015...RESULTS: From 156 potential studies, five were considered to be eligible for inclusion in the study. A total of 23 348 patients (657 who had undergone bariatric surgery, 22 691 who had not) were analysed. The evidence-base was moderate in quality. There was no statistically significant difference in outcomes such as superficial wound infection (relative risk (RR) 1.88; 95% confidence interval (CI) 0.95 to 0.37), deep wound infection (RR 1.04; 95% CI 0.65 to 1.66), DVT (RR 0.57; 95% CI 0.13 to 2.44), PE (RR 0.51; 95% CI 0.03 to 8.26), revision surgery (RR 1.24; 95% CI 0.75 to 2.05) or mortality (RR 1.25; 95% CI 0.16 to 9.89) between the two groups. CONCLUSION: For most peri-operative outcomes, bariatric surgery prior to THA or TKA does not significantly reduce the complication rates or improve the clinical outcome. This study questions the previous belief that bariatric surgery prior to arthroplasty may improve the clinical outcomes for patients who are obese or morbidly obese. This finding is based on moderate quality evidence. 
Other Possible Factors

Clin Orthop Relat Res. 2015 Oct;473(10):3163-72. doi: 10.1007/s11999-015-4333-7. Epub 2015 May 21. Low Albumin Levels, More Than Morbid Obesity, Are Associated With Complications After TKA. Nelson CL1, Elkassabany NM, Kamath AF, Liu J. PMID: 25995174
BACKGROUND: Morbid obesity and malnutrition are thought to be associated with more frequent perioperative complications after TKA. However, morbid obesity and malnutrition often are co-occurring conditions. Therefore it is important to understand whether morbid obesity, malnutrition, or both are independently associated with more frequent perioperative complications...METHODS: The National Surgical Quality Improvement Program (NSQIP) database was analyzed from 2006 to 2013. Patients were grouped as morbidly obese (BMI ≥ 40 kg/m(2)) or nonmorbidly obese (BMI ≥ 18.5 kg/m(2) to < 40 kg/m(2)), or by low serum albumin (serum albumin level < 3.5 mg/dL) or normal serum albumin (serum albumin level ≥ 3.5 mg/dL)...RESULTS: Mortality was not increased in the morbidly obese group (0.14% vs 0.14%; p = 0.942)...The group with low serum albumin had higher mortality than the group with normal serum albumin (0.64% vs 0.15%; OR, 3.17; 95% CI, 1.58-6.35; p =0.001)... CONCLUSIONS: Morbid obesity is not independently associated with the majority of perioperative complications measured by the NSQIP and was associated only with increases in progressive renal insufficiency, superficial surgical site infection, and sepsis among the 21 perioperative variables measured. However, low serum albumin was associated with increased mortality and multiple additional major perioperative complications after TKA. Low serum albumin, more so than morbid obesity, is associated with major perioperative complications. This is an important finding, as low serum albumin may be more modifiable than morbid obesity in patients who are immobile or have advanced knee osteoarthritis.
HSS J. 2017 Feb;13(1):66-74. doi: 10.1007/s11420-016-9518-4. Epub 2016 Aug 16. Hypoalbuminemia Is a Better Predictor than Obesity of Complications After Total Knee Arthroplasty: a Propensity Score-Adjusted Observational Analysis. Fu MC, McLawhorn AS, Padgett DE, Cross MB. PMID: 2816787
...METHODS: TKA cases were identified from the National Surgical Quality Improvement Program from 2005 to 2013... Malnutrition was defined as hypoalbuminemia (<3.5 g/dL). Patients were classified by BMI as follows: non-obese (18.5-29.9), obese I (30-34.9), obese II (35-39.9), or obese III (≥40). Postoperative complications were compared across obesity and nutritional statuses. Multivariable propensity-adjusted logistic regressions were performed to determine associations between malnutrition, obesity, and 30-day outcomes. RESULTS: There were 71,599 cases identified, with 34,800 (48.6%) having albumin measurements...Malnutrition prevalence increased with BMI (6.1% in obese III vs. 3.7% in non-obese). With propensity-adjusted multivariable analysis, obese III was the only obesity class associated with any complication, wound complication, and reoperation. Hypoalbuminemia was a stronger and more consistent independent risk factor, for any complication, wound, cardiac, or respiratory complications, and death. CONCLUSIONS: Hypoalbuminemia is a more consistent independent predictor of complications after TKA than obesity. Strategies for medical optimization of these conditions should be investigated.
Antibiotic Dosing and Surgical Infections

Acta Orthop. 2016;87(2):132-8. doi: 10.3109/17453674.2015.1126157. Epub 2016 Jan 5. Body mass and weight thresholds for increased prosthetic joint infection rates after primary total joint arthroplasty. Lübbeke A1, Zingg M1, Vu D2, Miozzari HH1, Christofilopoulos P1, Uçkay I1,2, Harbarth S3, Hoffmeyer P1. PMID: 26731633
...We included all 9,061 primary hip and knee arthroplasties (mean age 70 years, 61% women) performed between March 1996 and December 2013 where the patient had received intravenous cefuroxime (1.5 g) perioperatively. The main exposures of interest were BMI (5 categories: < 24.9, 25-29.9, 30-34.9, 35-39.9, and ≥ 40) and weight (5 categories: < 60, 60-79, 80-99, 100-119, and ≥ 120 kg). Numbers of TJAs according to BMI categories (lowest to highest) were as follows: 2,956, 3,350, 1,908, 633, and 214, respectively. The main outcome was prosthetic joint infection. The mean follow-up time was 6.5 years (0.5-18 years). RESULTS: 111 prosthetic joint infections were observed: 68 postoperative, 16 hematogenous, and 27 of undetermined cause. Incidence rates were similar in the first 3 BMI categories (< 35), but they were twice as high with BMI 35-39.9 (adjusted HR = 2.1, 95% CI: 1.1-4.3) and 4 times higher with BMI ≥ 40 (adjusted HR = 4.2, 95% CI: 1.8-9.7). Weight ≥ 100 kg was identified as threshold for a significant increase in infection from the early postoperative period onward (adjusted HR = 2.1, 95% CI: 1.3-3.6). INTERPRETATION: BMI ≥ 35 or weight ≥ 100 kg may serve as a cutoff for higher perioperative dosage of antibiotics.
Media Articles on Joint Replacement Restrictions on BMI











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Sunday, 30 July 2017

Fat Liberation is for Fat People with Disabilities Too

So if you read my previous post, you’d know that almost two months ago I had a rather spectacular fall (total dignity stripper) and did myself some considerable injury, including a fractured ankle, which has me in a moon boot. I’m really lucky, I’m not in a huge amount of pain, more sore than acute pain, and I’m pretty mobile despite the moon boot. I can walk fairly well, and though my mobility is somewhat compromised, I can still get around and live my life not all that much differently to I was pre-fracture. I’m embarrassingly slow up and down stairs is the worst thing.

However, even in my privileged position, I have experienced some issues with other people’s attitudes and behaviour since my mobility has been compromised. People walking at me or into me, some make snide comments about my ankle injury being “because she’s so fat”, an old woman on the bus asking me if I fell because I’m fat and then saying, “Well with your size I bet you went down hard.” (FYI, I fell because a patch of footpath was old and lumpy.) Or people kvetching because I’m so slow on stairs when I can’t avoid them altogether. You try walking up or down stairs in a huge boot when your ankle doesn’t bend.

I can only imagine the garbage that other fat people with disabilities (fat PWD) are subjected to.

People with disabilities (PWD) already have to deal with enough stigma, discrimination and general douchebaggery from non-disabled people, but add fatness to the equation and a whole raft of new shittiness is added.

Fat PWD are accused of “causing” their disabilities because they are fat, are accused of “just being lazy” or treated like even more of an inconvenience than thin PWD. It’s hard enough for PWD to get the equipment and services they need, and for many of we fat people to get equipment, clothing and services that fit our bodies – the two issues compounded make it even more of a burden for fat PWD to bear.

Just as a small example, a friend mentioned to me when I said that I had to get a boot to be aware that it may be difficult to get one to fit me, as she had trouble finding one that would fit her calf, and that eventually they had to pad a very large boot out in the foot for it to fit her calf. I’m fortunate there, I have big feet, which means a bigger boot, and my legs are proportionately smaller than the rest of me. But I know how hard it is for many fat women to find regular wide calf boots, let alone medical ones!

I have another fat friend who has a chronic health issue that means she needs access to disability toilets. She’s not visibly disabled, so she cops a lot of heat from strangers who make comments about “you’re fat, not disabled”. Nobody should have to justify their use of accessible toilets to bloody strangers! She has the same issue with disabled car parks.

Fat people are already beaten over the head with the health stick, throw disability and/or chronic illness into the mix and we just can’t win. Even though many chronic illnesses and disabilities can cause or are correlated with weight gain, our bodies are scrutinised further simply because of their fatness, regardless of our physical ability or levels of health. We’ve all had medical professionals prescribe weight loss for things wholly unconnected to weight (sore throats, injured bodies, reproductive system issues etc), how difficult must it be for fat PWD to get proper diagnosis and treatment of illnesses, injuries and other conditions.

As part of the fight to have the full humanity of fat people recognised by society in general, we need to make sure we are including fat PWD. Fat PWD should be able to advocate for themselves, get adequate medical treatment and suitable equipment to fit their bodies, as well as the basic dignity of being able to exist in society without stigma or vilification for their bodies for either disability or fatness.


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Friday, 28 July 2017

Fatshion: Modcloth Stylin’

Disclosure: I received products in exchange for my opinions. All opinions are 100% mine. Hi friends! I’m partnering with ModCloth today to show you some rad fat fashions! Did you know that...

Read more here!

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Thursday, 27 July 2017

the HAES® files: A Tale of Two Worlds: HAES® and WLS

by Alida Finnie, MSc, RD, CDE

I’ve reached the moment in time for me to come out of the closet.  I’ve been thinking about it for quite some time and mustered the strength to reveal what feels like imbecility rather than courage.  Who knowingly puts themselves out there with the risk of being shunned in not just one but both worlds?  I worry to be seen as straddling the fence thereby offending both sides and risk being an outcast.  I worry “no man is an island” will ring deafeningly false in my case…

There are only a handful of people who know I align both as a Health at Every Size® (HAES®) dietitian and work at an assessment centre for bariatric (weight loss) surgery.  It feels like I’ve been hiding a filthy secret and it is petrifying to open up about it.  But I’ve now reached a point where I am as prepared as I ever will be to share my experience in my seemingly double life.

I’ve worked at a bariatric surgery assessment centre for about two years.  On some level I’ve always wanted to live in a world of acceptance because I feel like I have an anaphylactic reaction to conflict.  Paradoxically, I’ve also taken a deep dive into the HAES® paradigm and non-diet approach in the past two years.

I don’t yet fully understand why I decided to jump into arguably opposite worlds at approximately the same time but I will do my best to explain.  I’ve always believed I don’t have the right to assume I know what’s best for my clients because I simply do not live in their shoes.  I do my absolute best to answer my clients’ questions with unbiased information followed by a gentle introduction to ideas they may not be aware of to help inform their decision.  Because you don’t know what you don’t know, right?  I guess my hope is that by being in both worlds, I can help people find their own harmony within.

What I would give to see a shift in our culture to accept all bodies of all sizes, shades and abilities! I believe this is the best way to support every body’s well being.  I am painfully aware this is not yet the world we live in… but a girl can dream, right?

Until that day, because I live in a body that is privileged (Caucasian, relatively “small”, without physical disability and cisgender), I know I will never be able to understand the depths of pain others feel by living in the “wrong body” dictated by our unaccepting culture.  I can’t judge someone for wanting to fit into this world with whatever means they feel they need.  Although surgery is a trauma to the body, I guess I see living in this world with the wrong body as a trauma to the spirit.  Who am I to judge how someone decides to fit into this world?

Until we find that place of peace where all bodies are accepted, I will continue to support resilience for both those who choose HAES® and those who choose surgery in the best ways I know how.

In fact, I am starting to see these two worlds intersect, at least in small pockets.  I am privileged to be part of a social media group that helps people who’ve had or are considering bariatric surgery discover how to integrate Intuitive Eating (non-diet approach to eating) so they can live more engaged lives.  The goal of the group is not to promote surgery, but to provide a supportive arena for those with weight concerns to learn how to heal their relationship with food and their bodies – with or without surgery.

I find that group members are relieved to hear it is completely natural for the mind and body to rebel against rigid food rules and that bodies are naturally diverse in size.  There is in fact NOT something fundamentally wrong with them, as the sad myth of our saturated diet culture leads us to believe.  Being told their minds and bodies DO NOT have to be at war with one another is sadly something most members have never heard nor experienced.  I do my best to help this group as well as those I see in the clinic navigate between the significant level of structured eating required to prevent malnutrition and the flexibility of eating with body attunement (Intuitive Eating).

Although I have definitely not mastered how to pair these two worlds, I continue to seek out stories of the misunderstood in hopes they feel heard, in hopes they feel accepted, in hopes they feel a sense of belonging.  If they don’t feel a sense of belonging out in the world at large, then I hope they can find it in my office nook.  If they’ve really experienced progress, they start feeling a sense of harmony in the sacred space where their mind and body meet.  This inner strength will hopefully give them a shield against the harsh realities of weight stigma in our world.  Surgery or not, this sense of safety is what I dream of for all humans alike.

 


Alida Finnie, MSc, RD, CDE is a Registered Dietitian & Certified Intuitive Eating Counsellor.  She is passionate about making peace with food and helping you do the same!  If you’re exhausted from pinging back and forth between food guilt and deprivation with constant body worry, she is here to help guide you back to Intuitive Eating.  She helps you learn all the strategies you need to eat with confidence and without dieting or food rules. You can connect with her at http://ift.tt/2uB39gq



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Tuesday, 25 July 2017

Yoga, Sizeism, and Randy

Talking NonsenseA fat yoga instructor and blog reader asked that I blog about this, and it’s my pleasure to do so because it’s important that we discuss the ways and places that fatphobia rears its oppressive head, and that we remind ourselves that fat bodies aren’t the problem, fatphobia is.

The fat yoga instructor asked the 20,000+ members of a fat yoga teachers group on Facebook to please consider dealing with any weight-based biases they might have that are keeping them from being able to properly welcome and teach fat students:

Yoga one

A svadhyaya is an introspection or self-study. “I’d like to ask all y’all to do a little svadhyaya…” Sounds like a reasonable request to me, but apparently not to Randy Hodur who took it upon himself to speak for most of the group, insisting that the post offended a whopping 90% of its members.

Despite having to deal with someone proving that he is an asshole by pulling percentages out of it, the OP remained calm and collected:

Yoga 2

As if striving to prove the OP’s point for her, Randy immediately misplaced all of his shit (trigger warning for misogynist bullshit and language from here on out. Feel free to skip Randy’s messages if you don’t feel like dealing with it.)

Yoga 3

Remember – this isn’t some pathetic reddit fat hate group, this is a professional group for professional yoga professionals…

Yoga 4

It’s ending with “just a thought” that really puts the shit icing on this crap cake. I’m not 100% certain that anything he’s said here qualifies as a thought, but we’ll leave that analysis for another day. It turns out that Randy’s girlfriend owns a yoga studio and people in the group were wondering if maybe nobody should ever go there lest they run into Randy.  He decided to fix the situation by attempting to win gold in the Non-Apology Olympics:

yoga 5

We’ve replaced this actual apology with some bullshit…let’s see if they notice…

Yoga 6

And it goes on…because it wouldn’t be a real non-apology unless the person who did terrible things attempted to make themselves the victim

Yoga 7

There is a great breakdown of the “apology” here.

Randy’s girlfriend reach out to the fat yoga instructor to apologize for her boyfriend’s abuse and to assure her that Randy does not teach in her studio, which is definitely a relief.

The Yoga world has many issues including appropriation, racism, sizeism, ableism, classism, queer and trans phobia and more.  A great place to start understanding and dismantling these issues in addition to the excellent teachers mentioned by the OP (and in addition to ongoing svadhyaya) is Decolonizing Yoga.

In general, notice fatphobia when it happens, call it out when you can, and always refuse to normalize it or blame the victim.

Ready for a world where fitness doesn’t come with a side of sizeism:

Click Here to Register for the Fat Activism Conference

The Fat Activism Conference is all online, so you can listen by phone or on your computer wherever you are.  Plus you get recordings and transcripts of each talk so you can listen and read live and/or on your own schedule. The conference is happening October 6-8, 2017!

If you enjoy this blog, consider becoming a member or making a contribution.

Like this blog?  Here’s more cool stuff:

Become a Member! For ten bucks a month you can support fat activism and get deals from size positive businesses as a thank you.  Click here for details

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!

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



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Saturday, 22 July 2017

Artificial Sweeteners – No Surprise Here

Here’s a link to TLW’s other blog and a recent post about a recent study that’s been all over the news:

Artificial Sweeteners Associated with Being Fat – No Duh




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CPAP Adventure

I’m providing a link to my blog Thoughts from This Fat Old Lady, outlining the fun and games I went through trying to get my CPAP replaced when it unexpectedly died.

My CPAP Adventure




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Wednesday, 19 July 2017

Is Slate Not Hiring Fat People?

Yesterday I was moderating friend requests on Facebook and I was reminded that far too many people connected to social justice are still rampant weight bigots. I’ll be scrolling through someone’s profile and see them on the right side of all manner of social justice movements; supporting Black Lives Matter, Queer and Trans rights, opposing Donald and all he stands for. I’m ready to press the “accept” button when I see that they have posted and defended articles and memes engaging in crystal clear oppression of fat people.

This experience prepared me for reading Slate’s recent job posting for a Political Editor. No, I’m not looking for a new gig, I was reading the post after receiving an onslaught of e-mails from fat and disability activists who were horrified by the bullet under “Requirements

  • A fast metabolism and strong organizational skills

What the hell?

Are they really saying that they don’t want a Politics Editor with hypothyroidism? Or are they stating a preference for editors with hyperthyroidism? Is this an attempt to suggest that only the thin need apply? Did they not know that they could be in violation of DC Human Rights Act (which is one of few that protects from discrimination against appearance) and ADA/EEOC guidelines?

The question I was being asked most in the e-mails flooding my inbox was, “Why in the world would a fast metabolism have anything to do with an editing gig?”

I had heard this term in journalism before, so I had an idea about the misunderstanding, but I still felt it was a terrible choice of words for a job posting. I e-mailed Slate for comment.

Click here to read my full piece about this!

Ready for a world where we don’t use sizeist, healthist, ableist metphors in job descriptions?

 

Click Here to Register for the Fat Activism Conference

The Fat Activism Conference is all online, so you can listen by phone or on your computer wherever you are.  Plus you get recordings and transcripts of each talk so you can listen and read live and/or on your own schedule. The conference is happening October 6-8, 2017!

If you enjoy this blog, consider becoming a member or making a contribution.

Like this blog?  Here’s more cool stuff:

Become a Member! For ten bucks a month you can support fat activism and get deals from size positive businesses as a thank you.  Click here for details

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!

 

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

 



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Monday, 17 July 2017

The Biggest Loser – Ding Dong the Witch is Dead!

Don't let the door hit youon your way out!Reports are coming in saying that The Biggest Loser is cancelled. That’s excellent news and I could not be happier. Let’s recap this crap:

The Biggest Loser was a horror of a television show in which fat people were physically and mentally abused as they tried to lose as much weight as possible, as fast as possible, regardless of the danger, for a chance to win a tiny fraction of the amount of money that the show made off their abuse.

I am thoroughly convinced that if this show was shot with dogs rather than fat people it would have been pulled off the air after the first episode, because people wouldn’t have stood for this kind of mistreatment of dogs. The fact that fat people would subject themselves to this show is not a justification for the many abuses the show perpetrated.

Now the show finds itself under a cloud of suspicion as former “competitors” talk about the abuses that they suffered at the hands of their “trainers” and the show’s doctor, Robert Huizenga.

Click here to read the full piece, including how the show hurt not only their contestants, but also their viewers.

Want to create a world where The Biggest Loser would never get on the air in the first place?

Click Here to Register for the Fat Activism Conference

The Fat Activism Conference is all online, so you can listen by phone or on your computer wherever you are.  Plus you get recordings and transcripts of each talk so you can listen and read live and/or on your own schedule. The conference is happening October 6-8, 2017!

If you enjoy this blog, consider becoming a member or making a contribution.

Like this blog?  Here’s more cool stuff:

Become a Member! For ten bucks a month you can support fat activism and get deals from size positive businesses as a thank you.  Click here for details

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!

 

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

 



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Sunday, 16 July 2017

We’re Supposed To Worry that Dust Makes Us Fat?

You Forgot Your BullshitToday we have a “study” that illustrates two of the truly ridiculous things that often happen in the “science” of weight and health.

1. You can get funding and published for literally any anti-fat study you can imagine 

In the tiny study, cells from mice were exposed to dust samples from 11 (not a typo, just eleven) homes to see if they would be linked with metabolic disruption including triglyceride and preadipocyte accumulation.

2. The most scientifically illiterate journalists will be allowed to write about it

A piece about this by Henry Bodkin (who, on the same day, had a piece published titled “Wild boar pictured roaming streets of city centre at night”) appeared in The Telegraph. The headline was ‘Household Dust Makes People Fat, Groundbreaking Research Indicates.” Seriously Hank (can I call you Hank?) WT Actual F are you doing?

Even if we assume that Henry isn’t responsible for the headline, surely he’s responsible for the actual reporting.  His piece didn’t bother to link to the actual study nor was it clear about the study’s limitations.  But it began, ambitiously, People should keep their homes spotless if they want to avoid putting on weight, new research suggests.”

That delayed this piece being written by a few hours due to the concussion I experienced from banging my head against my desk.

What the researchers actually said was “Our results delineate a novel potential health threat and identify putative causative SVOCs that are likely contributing to this activity.”

The words “potential,” “putative,” and “likely,” are important here as they all essentially mean “maybe” and do not remotely translate to the ability to suggest – at with with any kind of journalistic integrity – that if your house has dust you’ll become fat.

Now parents (and, let’s be honest, predominantly mom’s in our misogynist society) of fat kids will be blamed and, perhaps more tragically, blame themselves for not keeping their houses dust-free enough. We need to shut this bullshit down.

Today I’ve seen no less than four articles that included some version of “Is [XYZ] Making Us Fat?”  If an article asks that, I immediately ask myself “is this article a fatphobic (and quite likely ableist, classist etc.) piece of shit?” Hint: the answer is probably yes.

People are lots of different sizes for lots of different reasons and  I would personally prefer that we affirm the diversity of body sizes and spend research money figuring out how to support the health and happiness of people of all sizes, rather than trying to prevent or eradicate people of a certain size.

If you’re sick of researchers getting funding to figure out how to eradicate fat people, join us at the Fat Activism Conference!

Click Here to Register for the Fat Activism Conference

The Fat Activism Conference is all online, so you can listen by phone or on your computer wherever you are.  Plus you get recordings and transcripts of each talk so you can listen and read live and/or on your own schedule. The conference is happening October 6-8, 2017!

If you enjoy this blog, consider becoming a member or making a contribution.

Like this blog?  Here’s more cool stuff:

Become a Member! For ten bucks a month you can support fat activism and get deals from size positive businesses as a thank you.  Click here for details

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!

 

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

 



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Saturday, 15 July 2017

A Quick Update

Well hello!  It’s been a while, hasn’t it?  I am going to work hard to remedy the dearth of posts over the coming weeks.  I miss writing here so much, I need to re-focus on it.

So what’s happening?  Well, firstly I want to thank everyone who contributed to my GoFundMe for the Sydney Cyberhate Symposium.  It was a success and I attended last week and gave papers at both a panel for ANZCA at Sydney University, and the symposium itself.  I deliberately remained fairly quiet about it all before the event, as I and others were understandably nervous that giving away too much information might draw some fresh abuse and harassment either at the events themselves, or online in general.  Both events were amazing and I will be writing more about them shortly.  I am also hoping to get a copy of the video recording of my keynote so that I can share it.

The other big happening in my life is that I’m hobbling around in a “moon boot” after taking a rather spectacular fall about six weeks ago.  I mean the fall itself wasn’t spectacular, unless you count spectacularly embarrassing (thankfully the construction workers I fell in front of were really nice), but the injuries kind of were.  Chipped a bone in my wrist, broke the tip off my fibula, turned my right palm and left knee into bloody pulp and sprains in both the wrist and ankle.  We didn’t discover the fracture in my ankle until a couple of weeks after I did it, when it didn’t heal.  Then it was moon boot time.  I of course, could not leave the moon boot in it’s original grey form, so I decked it out with some woodland creature themed stickers.

I’m not sure how much longer I’m going to have to wear the boot, I can honestly say I’m quite sick of it already!  It has really reinforced to me just how little of our world is made easily accessible for people with disabilities – but I think that should be a whole post of it’s own.

Otherwise, some things I think you should all catch up with if you haven’t already:

Catch you all again soon!


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Friday, 14 July 2017

Epic 10th Anniversary Road Trip Post

Hi Everyone! Ryan and I finally got to go on our honeymoon at the end of last month; from June 22nd to the 28th we were on the road from Sudbury to Prince Edward Island and back. We had a wonderful trip with miles upon miles of beautiful scenery, nice folks, gorgeous beaches and even a whale!

A happy caucasian couple with brown hair smiles for the cameraOur first day we were on the road a long time, from Sudbury to Prescott ON to Quebec City We were a little late leaving because of poor planning on our part but once we got underway we had a great time. North Bay flew by, we took a pic of the Tim Hortons just about everywhere we stopped, and then we had dinner with Ryan's cousin's family and had our first look at the St. Lawrence River. It's very wide. We drove on after dinner through Montreal where, even at 9pm, the traffic was  heavy and everyone was speeding like whoa. We made it to Quebec City by about 1130pm and finally got to sleep at the Hotel Bonaparte. It was about a 12 hour day. The hotel room was nice, clean and quiet and the front desk clerk said he spoke 5 languages.

The next morning we had breakfast at the little restaurant attached to the hotel then hopped back across the St. Lawrence into Levis to drop our stuff at the Quality Inn, then drove down to the ferry terminal to walk over to old Quebec City. If you ever get the chance to visit please do! It was beautiful and incredibly well preserved. We walked all over the place for about 5 hours in the drizzle and didn't even care that it was raining. We saw the gates that protected the old city, nearly 400 year old shops and houses, the Citadel and even the Plains of Abraham.

This is the heart of Old Quebec City and it feels like you're walking abound Europe. Highly recommend! We had dinner at a quiet little bistro by a park where it just so happened a man was playing the harp. It was exactly what I wanted for our 10th anniversary dinner and I was just about in tears from joy. I had the duck, Ryan had a rabbit pastry pie and both were just to die for. Our server was attentive and warm and I made sure to leave a good review on Trip Advisor for Le Lapin Saute.

The St. Jean de Baptiste Festival started to get rolling by about 8:30 and our cameras and phones were dead so we decided it was time to go back across to Levis and get some sleep. The Quality Inn in Levis does *not* have a jacuzzi or hot tub like I thought, sadly.

The next day we drove from Levis QC to St Andrews in New Bruswick. It was a long drive day again and we kept losing time but we made it all the way there just in time for our whale watching tour. Scratch another thing off my bucket list! We saw a minke whale and we were the only people that day to see one at all. There were a few seals lounging about on the rocks in Paddy (Passamaquoddy) Bay but once we got out on the big water in the Bay of Fundy it got a lot colder and that's where we found our whale.

The sunset made him a bit hard to see but I didn't mind at all. It added to the atmosphere. We were able to get pretty close and keep tracking at a distance thanks to the type of boat we were on, a Zodiac. Highly recommend the Fundy Tide Runners if you're out that way and looking for a fun trip! Not expensive either. After we got back to port we went in search of some food and then our bed and breakfast in Chamcook.

We received a bit of a frosty reception for coming in so late and missing the 4pm check-in (we were still on the road from Quebec at the time and were late for our whale watching trip) and were informed that, since the owner had to be at church the next morning for 11 and would be leaving at 10:30am sharp, breakfast would be served at 830am so please be downstairs. It was definitely an unusual experience staying at a BnB instead of at a hotel and it's really turned us off BnBs to be honest.

The next morning after a broken sleep in an antique bed and delicious pancakes at 9am, we hit the road and followed the coastal route from St. Andrews. Along the way we stopped at a waterfall where Ryan had a swim, the Cape Enrage Lighthouse, like eight thousand beaches and salt marches, and finally the famous Flower Pot Rocks at Hopewell. They're truly an amazing and unique area of the world; most of the East coast is made of sedimentary stone like sandstone, so everything is built of layers and layers of old mud that's been dried and petrified into rock. It wears away thanks to the high tidal action and leaves amazing sculptures all over the place.

The Hopewell Rocks were definitely a highlight of the trip! We got to the site at low tide so we got to roam around a lot of the area even though the park was officially closed. Turns out the staff don't care if you're on site after hours or in the dark as long as your car isn't in the parking lot and you obey the safety signs. One of the larger, more famous of the rock formations collapsed earlier this year so there are lots of areas roped off  where you shouldn't go. If you visit please obey the signs!

I don't know why jigsy isn't letting me load vertical photos vertically....

We spent the rest of the evening poking around the beach and taking pics then driving over the enormous Confederation Bridge to PEI and our resting spot in Cavendish, the Shining Waters Inn. As promised, since we were so late (it was nearly midnight) our key was in an envelope stuck to the front door. No kidding. It's such a small community, and the RCMP station is across the road, that they felt comfortable leaving the key to the inn AND our room stuck to the front door inside the screen so we could get in. Amazing.

The next day after a bit of rain and a lovely breakfast at Rachel's we went to see the crown jewel (for me) of the trip; The Anne of Green Gables house. It was everything I could've wished for and more. I was so overcome with emotion I basically cried my whole way through the house. I took a few pictures but Ryan took more for me and at one point, upstairs in Anne's room, he just held me as I sobbed on him. It's hard for me to express what Anne means to me, especially to people who've never read Lucy Maud Montgomery's classic work. She was an orphan, a chatty little girl who was smart and funny and imaginative and she loved the world she lived in. Anne got straight As in school and became a teacher but in her heart she never let go of the irrepressible little girl who moved to Avonlea as an unwanted waif. As a teacher she cared deeply for her students and as a mother she taught me a lot about grace. Anne of Green Gables was the first series I read start-to-finish as a young person and it shaped me immensely. Being in the house Lucy called home and where she based the Cuthbert farm, with it's little bedroom upstairs that looked out on the Snow Queen and the Haunted Wood, Lover's Lane and all the rolling, beautiful land of PEI was a dream come true.

We spent the afternoon, after I recovered, driving south to the Point Prim Lighthouse, the oldest light on the Island, and investigating little beaches and spots along the way. Dinner was a proper Celtic themed pub in Charlottetown and then off to the Cavendish Beach for sunset and again, not disappointed. PEI is known for it's sunsets and boy was ours a treat. When we arrived I became very excited as I'd forgotten that Cavendish was the host of one of the best spots to see PEI's famous red sandstone cliffs! Are they ever red!

All red with sand dunes up behind us where we were lucky enough to spot a fox. Ryan wasn't quick enough to get a photo unfortunately. Then the sun set and it was a perfect ending to a nearly perfect day.

The next day we started for home, stopping in at Shediac Beach for an attempt at a swim but we were thwarted by little red jellyfish in the water. We stayed the night much, much later at a little motel on the side of the highway somewhere in Quebec called the Silver Maple, slept and got back on the road the next day. After a visit in Kingston to see some old, dear friends, we went home to the kids. Our honeymoon, though ten years late, was wonderful and we can't wait to get back to the East coast next summer.



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