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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Monday, 21 January 2019

“Things that were, things that are, and some things… that have not yet come to pass.”

Happy Twenty Wine-Teen, everyone! (Not claiming to have coined that one, but I also haven’t seen/heard it elsewhere, just saying! :P)

I am just so proud of all of us here to be still kicking and keeping on and doing our individual things in the world. You may not know it, but a lot of you keep me going on a regular basis! Thank you for that. Seriously! Even you lurkers, I see you!  and I love you! It’s been a wild time to be alive, that’s for sure. Time is such a weird thing, so let’s not dwell on it. We’ve all had hardships and struggles and great losses, time never really changes that. It’s just part of living. I’m grateful for every new day and every new night, I greet the moon with a knowing smile of appreciation for all the hard work she’s been doing for us here on Earth.
While I’ve never been one for annual rituals of the typical sort, I have begun what feels to be a big new chapter of my life. You see back in October I found out that I was losing my housing unexpectedly, but I had some notice, though no prospects. Actually, let’s step that back a bit because October was absolutely awful! My only two nearest women friends both moved out of state within a week of each other (separate states, separate people). Not only did my personal cheerleader and work soulmate move away, but so did my beloved dance partner. Then the housing thing came up. Housing opportunities for those not already wealthy in the San Francisco bay area are fucking grim, and that’s putting it lightly. Doing my best to not feel too sorry for myself, and truly overcome 24/7 by anxiety about housing and ending up in a horrible situation out of necessity, my landlord had told me that he also had to move due to insurance and city demands for updating the electrical on his property. I spent every day and night searching ads, apps, cold calling management companies, even resorting to scrolling google earth for possibilities. It was fucking dire! Suddenly not having my support system (well the lady half of it anyway) plus the uncertainty of having a roof over my head nearly did me in entirely. The week I had planned to take off of work for vacation was turned into a MUST FIND A PLACE TO LIVE tour, only to be sidelined day one by a severe cold and spent the remainder (including my birthday) sick in bed.
Amazingly my ex-husband and his wife invited me and my bffs over on another night (once I was feeling better) for a backyard get together around their fire pit that was just perfect. My puggo and I even stayed the night in their RV and the whole lot of us headed to Santa Cruz the next morning for a hot brunch spot that had a menu for dogs! We had the best time and it really made up for being sick on my bday. I’m so grateful to have the friendships that I do, especially with my ex, I know how rare that is. They all made me feel so special and cared for and the puggo had the time of his tiny life (can you believe he’s 9 now?!).
I came very close, twice, to signing a lease on a terrible apartment. I mean, it was a shoebox masquerading as a studio apartment (small by even NYC standards, lemme tell ya!). It didn’t feel safe and despite the insistence from the management company, I kept hesitating. Something just wouldn’t let me sign. I listened to my gut and after a week of back and forth and a second inspection I decided not to sign. This actually freaked me out more than I can even put in words. Basically I was consumed with, “Who do you think you are to turn down housing, any housing at all?!?! You’re gonna be fucking homeless you idiot loser!” Yeah, that asshole is in my head sometimes, but I knew my gut would steer me in the right direction. After weeks of all of this hysteria-level of searching, I randomly came across a place on craigslist. I had given up on craigslist as it is 99.9999% scams galore, but randomly, after weeks of not even checking it, I checked and found a place and went to see it the same day. When I saw the building I wasn’t impressed, but the unit itself was everything I’d hoped for, if not a bit more than I wanted to pay in rent. I tried to sign the lease right then and there but the manager insisted I consider it over the weekend and sign on Monday. I did, it’s mine, and I moved to a new town December 1st! It was super scary and crazy making, and yes many friends offered to help, but I got the whole fucking thing done myself (hired movers of course) and even unpacked 80% of my house before xmas!
You have no idea how scary this all was for me. Housing has always been a terror-inducing issue in my life, since my earliest of memories. And as time went on in my apartment hunting it became apparent to me that I was very likely lied to about the reasons for my needing to move. But once I had moved all my worries went away! (Okay, only sort.) I mean, signing a lease in my own name, being 100% responsible for all of my rent and deposit and insurance and the whole shebang?! Honestly, it was scarier than my wedding day! (I mean at least then I knew what I was getting into! Hahahaha!) It was a tough move, I was able to take some time off to get ALLLLLL the packing done. I couldn’t have accounted for a sudden change in my anxiety symptoms though. Suddenly I’d be frozen, just still as can be, my mind racing and screaming for my limbs to jump back into action, but I couldn’t snap out of it. I later discovered that this is quite common with more severe anxiety sufferers, and well my PTSD-C ain’t nothing, and boy how your mind and body can change as we age! Whew! I’m fortunate to have access to legal cannabis and well informed enough to know what I needed to push through and get everything done (Sativa is my jam, keeps me focused and gives me an energy boost when I need it, but would never use for/at work). It was a lot to handle, but I did it, dammit!
The first few weeks felt surreal. My last place was a tiny in-law studio, my bed was literally built into a box in the wall. It was quirky but it got me through some of the worst parts of my adult life, so for that I am thankful af! My new place is a true one bedroom apartment in an older building in a small working class neighborhood and I love it! I have hardwood floors in every room! They don’t all match but who cares?! I have a nearly normal sized kitchen with a dishwasher (!!!) and new stove. I even have a backdoor with a little yard so my doggo can go out when it’s too rainy for a full walk (we’ve had some heavy storms). I have my own bedroom with a door I can close! It feels ginormous! It’s not, but it feels like a fucking palace to me and I’m still getting used to it. I have a bathroom with a tub and shower, my old place had only a standup shower. It’s so much easier to bathe the puggo in a tub than trying to keep him from escaping the walk-in shower! Ha-ha!

I invited the bffs for xmas nibbles and drinks and enjoyed the results of that motivation for unpacking and decorating in time for those festivities. And my nibbles were a hit! I made a secret concoction for them to each take home and enjoy (my own take on a halloween themed cocktail that I switched up to more winter aromatics). My new bathroom I decked out in white and I still can’t believe that was a choice I willingly made. I have always hated white! Always! But, I love it in my bathroom! I got a ruffled fabric shower curtain and a crochet trimmed rug. It all came together so easily and I just love it. I’m still figuring some things out. Like my bedroom is still in boxes. But the rest of the place has really come together and it feels like my actual home! It’s perhaps a bit lonely, but I have friends and enjoy the hell out of my butter-spinster-hermit life most of the time. I’ve reconnected with a couple of old friends I’d previously lost touch with and have enjoyed their company. OH! I also asked for and got a raise! This was right before my move, actually, so that was awesome! Getting used to my new rent and creating a new budget for myself is still a work in progress. This new rent definitely sets me back quite a bit as far as paying off my debt, but again, I love it and I know it was the right choice. Please send out all the good vibes that my lil’ Toyota lasts me another couple of years, though!

My job has been mostly great, to be honest. I’m getting to do things and plan things on a scale I haven’t before, so that’s been fun. I have a great working relationship with my boss and the company I work for is doing really well. It’s not without it’s issues, but I think I’m in a good place over all right now. I’ve been doing a lot of self work and reflecting, too. I am always suspicious of anyone from the past popping up, but neither of the two people who have come back into my life ever betrayed me or caused any major drama or anything. Though I will always be a bit at arm’s length with them both, that is more to do with my issues than anything to do with them, really. I know this and I accept it, I don’t feel it’s a poor trait at this point so I’m just rolling with it. I have had some time to pause and really look at some of my own past toxic behaviors and beliefs and I have been amazed at just how much that simple thing can do to improve one’s mental health and self esteem. Like, look, we all gotta start from somewhere, and where I am right now is where I am and if that means having to unlearn and relearn some things others may have sooner is not for me to be concerned with. Just having the capacity to do this self work is a privilege.
Having this big new space to myself was at first a bit overwhelming. I wanted to decorate everything all at once, but I’m finding that my taste in things has been changing and I have been enjoying that as I go. I decided to forego the usual area rug focal point of your average American living room in order to preserve the open space and hardwood flooring so that I may get back into dancing again. I have always danced, but I mean, getting back into developing my own choreography from a place of joy and experimentation, not for a show. I haven’t done that in almost ten years. It used to be a natural part of my life. I would love to host a monthly gathering of some sort. My horoscope mentioned my wanting to make my house warm and inviting in order to host a salon and I’m not sure what that means in the modern sense, but my head goes to a mostly fictional Venice, Italy setting of artists and poets and wine and hearty discourse and lively discussions of philosophy. *LeSigh*
I have not dated over the past two years, except for a one off here and there. My last relationship was so unique that I guess I needed time to process and reprioritize and really work on getting my shit together once and for all. I feel very close to that “my shit is together” part, so close! Honestly, if I just had my bedroom unpacked and organized I’d pretty much be there! I am just at a loss for inspiration. Before my lil’ in-law studio I shared a house with a roommate, so I really only lived and worried about one room. Now I can do whatever and that is just too open a prospect for me to get my head around. I definitely need to do another wardrobe purge, though I did get rid of 5 bags of clothes and 2 bags of shoes when I moved. I need to dig deeper and really shed all I can and stick to the things I actually enjoy wearing instead of what I like looking at but never wear.
I want to write again, but I never feel I have anything worth while to say. I share my life with you here because it’s what I know and many have reached out separately to check in and see if I’m still breathing. Thank you for that. When feeling invisible is a part of my daily life, I forget that I have this incredible community spread out the world over. I cherish your existence! I would like to get more involved in fat activism again, but I have been focusing more on anti-racism and disability initiatives, and have struggled with and been challenged by my own fat politics these days. Going through some old docs I came across a bunch of poetry I wrote back in March of 2018 and it is actually pretty good, if I do say so myself. I’m just not sure people even buy or care about poetry anymore. Putting it online feels wrong to me, I do feel an urge to even handwrite a small chapbook or zine-style booklet for them. I’m uncertain. I want to feel that electric charge that art and creativity used to spark within me. I want to believe my best is yet to come in all aspects of my life. I’ve never been one for routines or disciplines, though. I’ve always been the random one who sort of sparks and shines and then fizzles out again.
I’ve been thinking a lot about what all of these different bit and parts of my lifetime mean now. It’s a collage unto itself, really. Careers and relationships aplenty! Ha-ha! I used to be more of a risk taker, and I don’t think that I’m not one now, but I feel less urgency with most things lately and appreciate a more languid approach to decisions and relationships in general. I mentioned not dating…I have realized this past year more than any before it how truly demisexual I am. I have been horny af but still unable to “get there” (ahem) even when thoroughly enjoying myself in the moment. I really need to feel a strong connection with someone, or have feels, if you will. It is nice to know myself so well, but it makes it much more difficult to get laid in a way that works for me. I have decided to dip a toe back into the dating pool once again, but I will not suffer fools nor waste time on those who are only self-interested/fulfilling. So yeah, I’m gonna be single awhile! Ha-ha! I am super okay with this, though. Like happy as fuck about it, honestly. I love my alone time. I think I am ready for someone and something awesome to happen, but I’m not chasing it.

I have thought about writing here for so long. It was really tough times for me through that last slog in my old place. It is amazing what we will grow accustomed to out of necessity. I had grown so used to feeling ashamed about my living situation and blamed myself and my mental illnesses and even my childhood and parents for how I was living. It wasn’t until my ex came to help haul away some garbage after the move that I realized how many limitations and restrictions I was living with in order to survive and most of which had zero to do with me or my brain and everything to do with access! Had you seen my place before I moved you would have easily, though wrongly, assumed I was a hoarder. Dearest readers, I am not a hoarder, though I am incredibly sympathetic to what it means to live that way. I believe that I and my bio mother likely have some semblance of hoarding but in the no energy to do a thing or have access to handling a thing and thus everything is too much and it just sort of envelopes your whole world I grew up in that environment.

No one talked about my mother having a mental illness but I knew all along she wasn’t like other moms. I knew I could never invite friends to my home growing up, and not being able to as an adult hurt my fucking soul. When I moved to that place, back to my hometown, I had a mental breakdown. I think not even a year later I had another when I lost two close friendships within a month of each other (absolutely not the two I just recently reconnected with). It’s quite possible I had another last xmas, but it was a dark time over all. To know deep within myself that I will never get back to that level of ick in my house again is such a huge relief! To admit that I’d reached out for help to a couple of organizations for help and got no response is upsetting, but in the end I feel better and more secure in myself knowing that I was able to handle it on my own (and I can be proud for asking for help even if I didn’t get it). There is that little asshole voice whispering, “but what if you couldn’t do it on your own? What if you were still there now?” and I cannot entertain that shit because it will pull me back down into the worst of it again. Nope. No more.

OH! I sang in the big moves show in October, too, but it was awful! My anxiety killed my voice, I had no air in my lungs, and it went all high-pitched and stringy. Luckily my dress made me look like a bombshell and hey if you shake your ass in a sparkly dress everyone cheers! Ha-ha! But I’m not so sure I’ll be attempting another vocal performance again…well maybe karaoke with a few cocktails, but that’s it! Ha! It was the last show before Tigress moved away and I had to do it, ya know? And I worked fucking hard rehearsing, too. Like I pushed myself to lose my voice and even vomit a few times, the song was tough but I wanted to own that shit! Oh well, you never can account for anxiety to suddenly fuck things up for ya. I was happy to be there to see Tigress’ number, she never ceases to amaze in both originality and costuming! That community specifically, feels like home to me a lot of the time. I don’t know if I’ll perform in the big moves big dance show this year. I won’t say I won’t, but I can’t say that I will, either. Luckily there’s plenty of time for life to show me the way.
So yeah! That’s what I’ve been up to. What the hell is new with you?!?! What are you pinning hopes on or looking forward to? My bff is coming to visit me in March and I cannot friggin’ wait! The last time she came for a visit she was stricken with a severe health issue so we didn’t really get to do any fun things. I haven’t seen her in over 5 years so this is gonna be BIG!!! We are gonna fat it uuuup!!! Ha-ha! So yeah, I just keep chuggin’ along doing my thing. I hope all is well with you and yours. I’m still here. If you ever need a sympathetic ear, hit me up! notblueatall@notblueatall.com I would love to hear from you! Or if you’d like to guest post here, I’d be into that!
Rad Fatty Love to ALL,

<3
S


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Saturday, 12 January 2019

Induction: Don't Break The Waters Early

Amnihooks, which are used to artificially break a woman's waters

New research (Pasko 2018) suggests that when care providers induce high BMI women, they should NOT break the waters in early labor (early amniotomy), especially in first-time mothers.

Breaking the waters early is commonly done to speed up labor. Sometimes it is done to place an internal monitor to monitor the baby more easily, but usually it is used to intensify contractions and shorten labor. Caregivers assume that this will help obese women avoid a cesarean.

However, the results from this new study suggest that early amniotomy actually increases the risk for a cesarean instead.

Study Details

In this retrospective cohort study, women with Class III "obesity" (body mass index ≥40 kg/m2) who were being induced  (n=285) were placed into two groups.

The first group (n=107) received early amniotomy before 4 cm dilation, and the other group (n=178) received late amniotomy.

The group who received early amniotomy had double the cesarean risk of those who did received later amniotomy.

In first-time (nulliparous) mothers, the risk for cesarean was tripled with early amniotomy. 

The length of labor was not shortened in either group. So the whole justification for using early amniotomy (shorter labor, fewer cesareans) for obese women was irrelevant.

An older study (Sheiner 2000) which examined induction by early amniotomy concluded:
In order to decrease the CS rates, induction should probably start with cervical ripening techniques in order to improve the Bishop scores.
Bishop Scores are a measure of how ripe and ready for labor the cervix is. Inductions on an unripe cervix are more likely to fail and result in cesarean, especially in first-time moms. Bishop scores tend to be lower at the start of inductions in women of size, which is probably an important factor in higher weight women's induction failures. 

Women of size also tend to have longer labors and generally take longer in latent (early) labor before reaching active labor. Yet despite this, research shows that early amniotomy is used more often in higher weight women. This needs to change.

How can early amniotomy (also known as Artificial Rupture of Membranes or early AROM) affect labor? When the water is broken, the cushioning around the baby is removed. Labor becomes much more painful, and there is risk for infection. The baby may be more likely to experience an abnormal heart rate (distress). If the baby is not well-positioned when AROM occurs, then the baby can become stuck in that position and have difficult getting out (labor dystocia). These factors can add up and result in a cesarean.

The take-home message from this study on high BMI women is obvious: Avoid having your waters broken before active labor begins (now defined as at least 6 cm dilation). This is especially important if you are a first-time mother. 

Of course, parents have to remain flexible in labor; plans may need to change. For example, if baby may be in trouble and external monitoring is not working well, then breaking the water sooner to place an internal monitor may make sense. But most of the time, amniotomy should not be done early in labor, especially in obese first-time mothers.

Induction Hints

It is best to await spontaneous labor whenever possible, so always question whether an induction is truly necessary. However, it's a hard truth that sometimes induction of labor does become medically necessary. If so, there are some lessons from research that may lessen your risk for cesarean. Most apply to women of all sizes but may be particularly relevant for higher weight women.

Ask your provider about your Bishop Score; if your cervix isn't ripe (Bishop score <5), ask if the induction can be delayed. If it cannot be delayed, ask for techniques to help ripen the cervix before pitocin is started and realize that you may need more time to reach active labor. Some research suggests that Foley catheter or prostaglandin (PGE2) inductions may be more effective in women of size than misoprostol (Cytotec).

Women of size may also need a larger dose of pitocin to keep an induced labor going strong, but this must be done cautiously because too much pitocin can send the baby into fetal distress. Wait and see how you and baby respond before increasing the dosage and go slowly with any adjustments.

Be sure you have a care provider who understands that latent labor tends to take longer in higher weight women and will give you plenty of time. Many cesareans in women of size are done before active labor, and many could probably be prevented if caregivers were more patient and waited longer before moving to a cesarean.

Be sure your baby is in an optimal position for birth before the induction if possible. Chiropractic care may help align the pelvis and maximize the space for an easier birth. If the baby is posterior (facing your front) in labor, ask your caregiver for manual rotation, which clearly reduces the risk for cesarean in several studies.

Maintain your mobility as much as possible and don't get stuck in bed on your back. Make gravity work for you. Upright positions reduce the length of labor and the risk for cesarean. Special positions like hands and knees or an exaggerated Sims position may help malpositioned babies turn more easily. You can read more aboutvarious labor and birth positions here.

As discussed, don't let the caregivers break the waters until you are well into active labor. If possible, let the waters break on their own. Keeping the waters intact as long as possible can help a malpositioned baby turn more easily.

Hire a doula to give professional labor support. One study found a cesarean rate of 13.4% in a group of first-time mothers with doulas, whereas the cesarean rate in the group without doulas was 25%. The difference was even more marked in those whose labors were induced; the group with doulas had a cesarean rate of 12.5%, vs. a 58.8% rate in those without doulas.

These ideas should improve your chances of a normal vaginal birth with an induction. Of course there are no guarantees, but rest assured that with enough time and patience, a reasonably ripe cervix, a well-positioned baby, and good support, many inductions in women of size can result in vaginal births.



Reference

Am J Perinatol. 2018 Nov 5. doi: 10.1055/s-0038-1675331. [Epub ahead of print] Pregnancy Outcomes after Early Amniotomy among Class III Obese Gravidas Undergoing Induction of Labor. Pasko DN, Miller KM, Jauk VC, Subramaniam A.  PMID: 30396229 
OBJECTIVE: We sought to evaluate differences in pregnancy outcomes following early amniotomy in women with class III obesity (body mass index ≥40 kg/m2) undergoing induction of labor. STUDY DESIGN: This is a retrospective cohort study of women with class III obesity undergoing term induction of labor from January 2007 to February 2013. Early amniotomy was defined as artificial membrane rupture at less than 4 cm cervical dilation. The primary outcome was cesarean delivery. Secondary outcomes included length of labor, a maternal morbidity composite, and a neonatal morbidity composite. A subgroup analysis examined the effect of parity. Multivariable logistic regression was used to adjust for covariates. RESULTS: Of 285 women meeting inclusion criteria, 107 (37.5%) underwent early amniotomy and 178 (62.5%) underwent late amniotomy. Early amniotomy was associated with cesarean delivery after multivariable adjustments (adjusted odds ratio [aOR], 2.05; 95% confidence interval [CI], 1.21-3.47). There were no significant differences in length of labor or maternal and neonatal morbidity between groups. When stratified by parity, early amniotomy was associated with increased cesarean delivery (aOR, 3.10; 95% CI, 1.47-6.58) only in nulliparous women. CONCLUSION: Early amniotomy among class III obese women, especially nulliparous women, undergoing labor induction may be associated with an increased risk of cesarean delivery.




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Wednesday, 9 January 2019

the HAES® files: To Be Seen

by Dawn Clark

When I came home from the ASDAH conference, I was repeatedly asked about my time there. How was it? Did you have fun? Did you learn anything? Who did you meet?

The simple answer to most of those people is; “I had a great time. I really enjoyed meeting everyone. I learned so much. And I learned that I have much to learn, especially regarding marginalized people.” But the deeper answer more confusing and difficult to understand. Deep down, when I reflect on that experience, I want to shout from the rooftops; “I WAS SEEN!!”

And this, for me, has been life-changing. For one of the few times in my life, I was seen for who I am, not what I weigh. Seen as someone who had stories of worth to tell, not someone to be ignored because of their size. Seen as having value, not someone who was lazy and a loser. I could commiserate with people about doctors and therapists. When I mentioned micro aggressions, people knew exactly what I was talking about. Smiles were met with genuine smiles. I wore a bathing suit in public for the first time in almost 25 years and it was greeted with cheers and clapping. When talking about accessibility, there was agreement, not argument.

It was amazing. It was also overwhelming. I didn’t want it to end. For the first time in what seems like forever, I felt safe. I felt as if I could be more of myself with no judgement.

But, like all conferences, the ASDAH conference did come to a close, and I did have to come home—and back to the “real world.” Within 24 hours, I was back to the good (or ill) intentioned weight-loss advice. I was back to the looks on the bus—to the world judging me by what I look like, not by who I am. Instead of health providers who were actively engaged in fighting fatphobia, I had to go to a doctor’s appointment where they insisted that they needed my weight in order to give me care (It was just a blood draw). I went back to a world where my body was once again under constant surveillance—a problem that everyone seems to need to fix.

But there is now a difference. Now, when I walk through this real, fatphobic world, I am less likely to apologize if I need accommodation. I am better equipped with how to talk to my doctor earnestly about my body and what I feel is appropriate. And I feel a little less alone when doing these small steps of self-advocacy. I have been seen. I have found community. I am not alone.

This sense of community has been a gift—and it’s one I want to share with other fat folks like myself. I recently attended a women’s retreat and had the chance to talk about HAES. Now I am still new to HAES, but I decided to take a chance. I got some skeptical looks, but some women really listened, hungry to hear that they didn’t need to destroy themselves for someone else’s ideal. Maybe they, like me, felt a little less alone.

In reflecting on all this, I think the biggest difference is that I have more hope now, something I did not have much of before.

Thank you for the gift of being seen.

 


Dawn Clark was born in Iowa but has spent most of her life in beautiful western Washington. After high school (where the band uniforms never fit), she moved to Alberta,Canada to attend college. You don’t understand the meaning of cold until you have spent it in the prairies. She now lives back in western Washington and works for a major travel company. She loves to fish, cruise, crochet, cook, and is very active in her church. Through her best friend, she is learning about HAES and has started down the road of being a advocate for herself and others. She attended the International Weight Stigma conference last year in Prague and had the tremendous honor of being one of the speakers at a workshop at the ASDAH conference in Portland in August.

 



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Monday, 7 January 2019

Before You Call A Fat Person at the Gym “Brave”

Bullshit FairyThere is a concept in Fat Activism called the “Good Fatty Bad Fatty Dichotomy.” coined by Kate Harding. Basically, it’s the idea that fat people should be treated differently based on health status or performance of “health” (foods eaten, exercise undertaken etc.)

There is a more complete discussion here. The end result of this is to create hoops that fat people have to jump through in order to be treated with basic human respect by the person who is creating the hoops and judging how well fat people are jumping through them.  It’s bullshit, of course, but it’s ingrained in our culture and it comes out often in memes that are well meaning, but messed up.  Here are some that I’ve corrected:

why-would-you-make-fun-of-a-fat-person

And while we’re on the subject –  fat people’s bodies are not “problems” to be “fixed.” Extra shame on the person who created this for besmirching the good named of Captain Picard.

Original pictures is a fat person on a machine at the gym, photographed from behind with the caption "Making fun of a fat person at the gym is like making fun of a homeless person at a job fair." This image and caption are crossed out, the image is copied on the right with the new caption "Making fun of a fat person or a homeless person is a shitty thing to do no matter where they are. Don't be an asshole."

Another version of this compares fat people in the gym to sick people at the hospital, which is ridiculous since it pathologizes fat bodies and suggests that they have some special need to go to the gym to “fix” themselves that thinner people don’t. Super extra shame on the person who created this for using homeless people as a tool in their bullshit good fatty argument.

goals-based-on-size

This person took the popular meme “confession bear” and turned him into “stereotyping, patronizing bear.” As Fat Activists and Health at Every Size practitioners who have been asked intrusive and clueless questions by perfect strangers at the gym (like “how much weight have you lost?”) can attest, this is crap. Don’t make assumptions about people based on their size – not at the gym, not anywhere else.

run-or-dont

Ugh.  People who are running are not morally better than people who are sitting on the couch. People who run faster are not morally better than people who run more slowly. We do not have to be “better” than someone else in order to be happy with ourselves.  I blogged more about this one here.

Or maybe you’ve seen the letter written to a fat person who was, one might assume, just trying to run around a track and not trying to be a muse for someone who wants a medal for not being as shitty and fatphobic as they possibly could.

As always, think before you meme and when you see memes that put some people down as a way to prop other people up you can remind the people who post it that it’s not necessary and, in fact, it’s extremely harmful. No more good fatty bad fatty BS please.

Did you like this post? If you appreciate the work I do, you can support my ability to do more of it with a one-time contribution or by becoming a member.

Like this blog?  Here’s more cool stuff:

The New Year Sale is on! – Give the gift of body love and/or get your own year off to a Size Acceptance and Health at Every Size start with discounts on books, online programs, and DVDs to get your year (or the year of the people you’re gifting them to) off to a great start, and save you some money! (Dances With Fat Members get even bigger discounts, so make sure to use your link on the member page.)

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.



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Thursday, 3 January 2019

Three Easy Ways to Know If A Diet Study Sucks

LiesOne of the most frustrating things about weight loss (so-called) research, is that the media often covers any weight-loss study as if the conclusions they claim have been proven beyond a shadow of a doubt when, in fact, much of the research is embarrassingly poor – often for profit by the weight loss industry. I get a lot of questions about how to evaluate studies, and it’s a topic that can get complicated fast, but here are some easy ways to evaluate a study about a purported weight loss technique

1. Did they take their time?

This is covered in greater detail here, but basically almost everyone can lose weight short term, but almost everyone gains it back within five years. So if a study doesn’t follow subjects for at least 5 years then it’s not a valid look at whether a weight loss method works for anything more than the short term.  (This is especially important with diet companies like Noom which both claims to be a “brand new” way to diet, and simultaneously claims that they offer “permanent” weight loss. Where are they getting their long-term data? If they are “brand new,” how many people who lost weight on their program could have died having kept it off?

2. Are these people?

When it comes to the study subjects, you might think that you should start with questions like “were the study participants diverse?” But you actually need to start with the question “were the study participants human?”

I can’t even count how many times that I’ve read an article about a study and asked myself “Wait – was this rats?” and then looked it up to find that it was, in fact, done with rats as subjects. And the reporter didn’t bother to mention that while droning on about how effective this new diet is.

3. Who are these people?

If the researchers did study humans, we then have to ask how representative the sample  (the group of people who participated in the study) is. Which is to say that who they study determines to whom the study results can be appropriately extrapolated. So if they only studied white cisgender dudes, that’s the only group we can expect the results to apply to (and that’s only if they had a large enough sample – included enough white cisgender dudes – to rule out individual differences.)

A number of assumptions in medicine that have been proven false (like the idea that heart attacks have the same symptoms regardless of gender) were based on researchers’ habit of studying 150-pound cisgender white men and then extrapolating those results to literally everyone. Many studies (not just weight loss, but all studies) under-represent People of Color and completely fail to represent Trans and Non-Binary people at all. Representative samples are a huge issue, and that’s not even getting into the variables they don’t control for. So you are looking for a study with a large, diverse sample.

To date, there is not a single study where more than a tiny fraction of people were able to maintain significant weight loss long-term, so don’t be suprised if you find the weight loss studies you are analyzing are lacking in study methodology, and subject success.

If you are interested in checking out an exhaustively researched paper supporting a departure from diet culture, I recommend you head over here.

Did you like this post? If you appreciate the work I do, you can support my ability to do more of it with a one-time contribution or by becoming a member.

Like this blog?  Here’s more cool stuff:

The New Year Sale is on! – Give the gift of body love and/or get your own year off to a Size Acceptance and Health at Every Size start with discounts on books, online programs, and DVDs to get your year (or the year of the people you’re gifting them to) off to a great start, and save you some money! (Dances With Fat Members get even bigger discounts, so make sure to use your link on the member page.)

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.



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Wednesday, 2 January 2019

Hospitals with Midwives on Staff Have Better Outcomes


Here are two recent studies showing that hospitals with midwives and doctors practicing together ("interprofessional" centers) have better outcomes than hospitals with only doctors. One study is on first-time mothers (nulliparous), and the other study is on women who have given birth before (multiparous), to separate out the possible effects of parity.

In first-time mothers, women were much less likely to be induced or have oxytocin augmentation of labor in interprofessional/collaborative centers. The cesarean rate was 12% lower in interprofessional centers too.

For multiparous mothers (multips), women were again much less likely to be induced or have augmentation of labor in interprofessional centers. The first-time cesarean rate was 36% lower, and the Vaginal Birth After Cesarean (VBAC) rate was 31% higher than in institutions with only doctors. Neonatal outcomes were similar between the two types of centers.

The implication here is that not only do midwives lower the rates of interventions without endangering outcomes, they also influence the hospital culture in a positive way. Doctors who work with midwives tend to be more flexible about interventions, less likely to push a cesarean without need, and more likely to support VBACs.

If you are considering a hospital birth, try to choose a hospital with both doctors and midwives on staff, one with low overall cesarean rates, and strongly consider hiring a doula for professional labor support. Most women can safely be attended by a midwife, so make that your first choice if you can. If a risk comes up that means that you need to see an OB or high-risk maternal fetal medicine (MFM) specialist, the midwife will refer you to one, probably one that is supportive of the parents' birth wishes whenever conditions allow.



References

Birth. 2018 Nov 11. doi: 10.1111/birt.12407. [Epub ahead of print] Midwifery presence in United States medical centers and labor care and birth outcomes among low-risk nulliparous women: A Consortium on Safe Labor study. Neal JL, Carlson NS, Phillippi JC, Tilden EL, Smith DC, Breman RB, Dietrich MS, Lowe NK. PMID: 30417436
...Our objective was to compare labor processes and outcomes for low-risk nulliparous women birthing in United States medical centers with interprofessional care (midwives and physicians) versus noninterprofessional care (physicians only). METHODS: We conducted a retrospective cohort study using Consortium on Safe Labor data from low-risk nulliparous women who birthed in interprofessional (n = 7393) or noninterprofessional centers (n = 6982). .. women at interprofessional medical centers, compared with women at noninterprofessional centers, were 74% less likely to undergo labor induction (risk ratio [RR] 0.26; 95% CI 0.24-0.29) and 75% less likely to have oxytocin augmentation (RR 0.25; 95% CI 0.22-0.29). The cesarean birth rate was 12% lower at interprofessional centers (RR 0.88; 95% CI 0.79-0.98). Adverse neonatal outcomes occurred in only 0.3% of births and were thus too rare to be modeled. CONCLUSIONS: The care processes and birth outcomes at interprofessional and noninterprofessional medical centers differed significantly. Nulliparous women receiving care at interprofessional centers were less likely to experience induction, oxytocin augmentation, and cesarean than women at noninterprofessional centers. Labor care and birth outcome differences between interprofessional and noninterprofessional centers may be the result of the presence of midwives and interprofessional collaboration, organizational culture, or both.
Birth. 2018 Nov 9. doi: 10.1111/birt.12405. [Epub ahead of print] Influence of midwifery presence in United States centers on labor care and outcomes of low-risk parous women: A Consortium on Safe Labor study. Carlson NS, Neal JL, Tilden EL, Smith DC, Breman RB, Lowe NK, Dietrich MS, Phillippi JC. PMID: 30414200
...We sought to use national United States data to analyze the association between midwifery presence in maternity care teams and the birth processes and outcomes of low-risk parous women. METHODS: We conducted a retrospective cohort study using Consortium on Safe Labor data from low-risk parous women in either interprofessional care (n = 12 125) or noninterprofessional care centers (n = 8996). .. women at interprofessional centers, compared with women at noninterprofessional centers, were 85% less likely to have labor induced (risk ratio [RR] 0.15; 95% CI 0.14-0.17). The risk for primary cesarean birth among low-risk parous women was 36% lower at interprofessional centers (RR 0.64; 95% CI 00.52-0.79), whereas the likelihood of vaginal birth after cesarean for this population was 31% higher (RR 1.31; 95% CI 1.10-1.56). There were no significant differences in neonatal outcomes. CONCLUSIONS: Parous women have significantly higher rates of vaginal birth, including vaginal birth after cesarean, and lower likelihood of labor induction when cared for in centers with midwives. Our findings are consistent with smaller analyses of midwifery practice and support integrated, team-based models of perinatal care to improve maternal outcomes.


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