Friday, 24 August 2018

Study: Pre-Conception Screening with Higher Weight Women

In 2017, researchers from Harvard Medical School and the Brigham & Women's Hospital published a study on pre-conception consults with "obese" women and the outcomes of those consults. This study pointed out a couple of glaring problems with pre-conception consults for women of size, but as always, the authors ended up focusing on the wrong problem. 

Study Details

The consults were mostly done for women with fertility concerns who were seeking fertility treatment. 28% had a pre-existing diagnosis of Polycystic Ovarian Syndrome (PCOS), which often leads to sub-fertility in women of size. These consults were not with regular OBs or midwives; these consults were with Maternal-Fetal Medicine (MFM) specialists, who mainly see complicated or extra risky pregnancies. If anyone should have gotten pre-conception counseling right, it should have been these docs. But what researchers found were significant problems.

The researchers reviewed the charts of 162 consults between 2008 and 2014. They were looking for 3 main things in the records:
  1. Documentation of discussion of obesity-related risks and complications
  2. Documentation that lab tests were performed to be sure blood pressure and blood sugar were normal
  3. Whether doctors advised weight loss before pregnancy, whether people took the weight loss advice via consults with the hospital's Weight Management Program, bariatric surgery, or other programs, and if so, how much weight was lost
Discussion of Obesity-Related Risks

Unsurprisingly, doctors talked about obesity-related risks in 96% of the MFM consults. With all the emphasis in the media and in the research about the risks of obesity in pregnancy, that's to be expected. We can only hope this was done in a neutral and fair way, rather than through scare-mongering and exaggeration, but there's not much information on how the risks were presented.

Discussion of potential risks is part of a medical professional's job, so no one is suggesting that this should not have been covered. But how they discuss risk matters. Is it done in a gloom-and-doom way, is it shaming or condescending, or is it simply information provided without judgment? Do doctors emphasize ways to mitigate risk beyond losing weight? Are risk ratios the only method used (which tends to inflate the perception of risk) or are actual numerical incidences used? Do doctors acknowledge that complications are not a foregone conclusion and that many women of size can have normal pregnancies and healthy babies?

Risk discussions about weight are difficult and can be fraught with emotions. Shaming and scolding backfire because most people stop listening and tune out. Most people of size have experienced such negative contacts with healthcare professionals that they have learned to block out the gloom-and-doom predictions. Exaggerating the risk results in people not taking the discussion seriously and not listening to the important advice that might be given on prevention.

We need a different way to discuss risk surrounding weight in pregnancy. Couch the discussion in neutral terms without being judgmental. Use actual incidence figures to give numerical context to risk ratios, and make sure patients understand the difference. Acknowledge that positive outcomes are possible, and suggest ways (beyond just focus on the scale) to mitigate the risk. This is much more empowering to women and more likely to be heard and heeded. Potential complications can be discussed, but with explanations of how such problems would be addressed whenever possible. Don't center the entire discussion around weight; encourage good habits like regular exercise without tying it to the scale.

Screening for Diabetes and High Blood Pressure

Part of every preconception consult for people of size should be measuring blood sugar and blood pressure. High blood sugar in early pregnancy is strongly tied to birth defects. High blood pressure issues in pregnancy often lead to too-small babies, premature births, and sometimes even death for mother or baby.  Discovering these conditions before pregnancy and getting them under control before conception can definitely improve outcomes.

Shockingly, only about half of obese women were screened for diabetes and high blood pressure at the MFM consult:
Screening for diabetes and hypertension occurred in 48% and 51% of consults, respectively.
This is very surprising, and a tremendous missed opportunity. While most obese women do not have diabetes or blood pressure issues before pregnancy, some certainly do, and those pregnancies are responsible for much of the less ideal outcomes from high BMI pregnancies.

A preconception consult is the perfect time to discover whether there are pre-existing problems, take action, and hopefully prevent some of the worst-case scenarios. Therefore it's stunning that MFM specialists screened only half of the people of size for these conditions ahead of time.

This is the most important finding of this study, in my opinion. Medical professionals need to be sure to test for these conditions before pregnancy whenever  possible. People of all sizes should have their blood pressure taken (with the correct-sized cuff) and a medical history taken. People who are at increased risk for diabetes (such as higher-weight people, people with PCOS, people with a strong family history of diabetes, etc.) should also have their blood sugar tested pre-conception if possible.

If your care provider does not order these tests in your regular check-ups, then you need to take matters in your own hands and arrange for them to be done. Even if you are not planning a pregnancy, many pregnancies occur unplanned. Getting regular monitoring of your blood sugar levels and blood pressure if you are sexually active is simply common sense. So is taking a prenatal vitamin regularly.

Weight Loss Advice and Follow-Through

Because most doctors are taught that weight loss is the main way to prevent complications in high BMI women, advice to lose weight before pregnancy is common. The authors state:
Ideally, an MFM consult should not only inform an obese woman of the impact of her weight on fertility and pregnancy, but also equip her with strategies for weight loss.
In fact, it is that hospital's policy that all women with a BMI over 40 who are seeking fertility treatment should be automatically referred to the hospital's Weight Management program, "which includes calorie-controlled diet and liquid diet programs in addition to other medical treatments for obesity."

With a protocol like this in place, it's understandable that the researchers were disappointed that weight loss referrals weren't universally given in the consults. Just over half of participants were documented as having received advice on diet and exercise. As BMI went up, more were given such advice, as well as referrals to bariatric surgery, but it was by no means universal even at the largest sizes.

Researchers were shocked by how few women took active measures to lose weight. In the study,
27% of patients saw a nutritionist, 6% saw a provider for a medically supervised weight loss program, and 6% underwent bariatric surgery... The median weight change was a loss of 2.0 lb, or 0.6% body weight, over a median of 12 months.... Rates of any pregnancy and of ongoing pregnancy were not associated with whether women lost ≥5% body weight.
The authors of the study acknowledge that most women, especially those facing fertility challenges, don't want to delay treatment for the elusive dream of losing weight, and that this likely was why most patients did not opt into the Weight Management or bariatric surgery programs. Most began fertility treatments within a month or so after their MFM consult.

It should also be pointed out that the median weight change was TWO POUNDS... not exactly outstanding results. Those who waited and lost more than 5% of body weight did not have more pregnancies, calling into question whether weight loss is as effective for fertility as doctors assume.

But of course doctors ignored these findings and just called for more weight loss emphasis in pre-conception consults. The authors state:
...the consults were unsuccessful in meaningfully effecting pre-pregnancy weight loss. In this study, only 19% of the participants with follow-up weights achieved ≥5% loss, and only 5% achieved ≥10% loss. We believe that increased emphasis is needed on weight loss resources, including discussion of lifestyle modification and referrals to specialty obesity treatment services, e.g. bariatric surgery. In addition, MFM providers and referring REI providers must be allied in counseling women to delay fertility treatment and conception to focus on weight loss. This recommendation is more nuanced in the case of women of advanced maternal age, when postponing fertility treatment may result in loss of the fertile window and may therefore be untenable. ...More emphasis is needed on weight loss resources and delaying pregnancy to achieve weight loss goals.
Here we go, back to the same old medical mentality. It's all about losing weight before pursuing pregnancy, even when they can see that most women are not interested in that, even when most women lost very little weight despite trying, and even when such weight loss may not make a difference in live birth rates.

It's like doctors are incapable of thinking outside the box. They know the colossal failure of weight loss programs but are in such denial they cannot admit that these basically useless. Instead, their answer is MORE emphasis on weight loss programs, with a fallback to bariatric surgery if all else fails.

It is telling that no acknowledgement was made of many people's long history of dieting ups and downs and the tremendous frustration of yo-yo dieting. Many patients are just done with radical weight loss programs because they know that they are not effective long-term and they are not willing to live like that.

Like most in the weight loss field, these researchers remained determinedly obtuse. It's weight loss above everything else, at any cost. And while some higher weight people are interested in this, many are not.

Discussion of Study

It's clear from the summary at the end of the paper that the main result of this study is going to be an increased pressure on MFM specialists to push weight loss before treatment. More pressure will be brought on doctors to refer patients to the hospital's Weight Management and bariatric surgery programs. The question is whether women will be free to accept or decline these programs at will.

It's one thing to offer someone access to weight management programs; some want this and that's their choice. It's another thing to browbeat women into these programs, and it's a completely different thing to require them. While this center did not deny higher BMI women access to fertility treatment without weight loss first, that seems to be the direction they are heading, and that's alarming.

Although these hospitals deny a profit motive, let's not forget that weight loss programs are big money-makers for hospitals, so financial incentives may also play a role. The weight loss industry is BIG BUSINESS and many doctors are utterly compromised by their ties to these programs. They may be unconsciously biased and not even recognize it. Ties to the pharmaceutical industry are treated with far more caution than ties to the weight loss industry, but money talks in the bariatric field as loudly as any other.

The biggest take-away from this study should not be that more emphasis on weight loss before pregnancy is needed. 

Instead, the most important take-away SHOULD be the fact that medical professionals are not adequately testing to make sure the woman is in reasonable health before pregnancy. 

The fact that only HALF of the women were not even tested for blood pressure and blood sugar issues, yet the study authors conclude that weight loss referral is the most pressing issue shows that medical professionals are too narrowly focused on the scale. They have blinders on and cannot see anything else.

Weight should not be used as a surrogate for whether a person is healthy. Instead, documentation of blood pressure and blood sugar and other labs should be done, and treatment of any problems initiated or adjusted if needed. That will likely have more downstream improvement of outcome than trying to ensure that all the women lose at least 10% of their bodyweight first.

That doesn't mean that lifestyle and health habits should be ignored. Instead, people's individual habits should be evaluated in a non-judgmental manner, and suggestions for improvements can be gently made to people of all sizes. Advice about nutrition doesn't have to be about restricting calories; combining proteins with carbs and limiting high glycemic index carbs may help prevent some complications without necessarily resulting in weight loss. Exercise can strongly improve outcomes, even if it doesn't lead to weight loss. Lab tests can be run to see if any particular nutrients are deficient and need boosting. Nutritional consults can be very useful if they are done right.

In the study, 27% of women were willing to see a nutritionist before pregnancy, while only 6% were willing to enroll in a Weight Management program. That means there is an opportunity here for a Health At Every Size® approach instead, which would emphasize healthy habits and food, regular exercise, and lab tests as measures of health instead of the scale. This may do more to improve outcome than trying to get women to lose 10% or more of their bodyweight.

Doctors need more tools in their maternal obesity toolbox besides weight loss. They need to think about prevention beyond just losing weight before pregnancy.

Testing for pre-existing conditions before pregnancy is a cornerstone of the toolbox. Too bad these researchers missed the bus on emphasizing this as their main message.


Fertil Res Pract. 2017 Jan 13;3:3. doi: 10.1186/s40738-016-0030-9. eCollection 2017. Preconception consultations with Maternal Fetal Medicine for obese women: a retrospective chart review. Page CM, Ginsburg ES, Goldman RH, Zera CA. PMID: 28620542  Full text here.
...The purpose of this study was to evaluate the quality and effectiveness of Maternal Fetal Medicine (MFM) preconception consults for obese women. METHODS: We performed a retrospective chart review examining 162 consults at an academic medical center from 2008 to 2014. The main outcome measures included consultation content - e.g. discussion of obesity-related pregnancy complications, screening for comorbidities, and referrals for weight loss interventions - and weight loss. RESULTS: Screening for diabetes and hypertension occurred in 48% and 51% of consults, respectively. Discussion of obesity-related pregnancy complications was documented in 96% of consults. During follow-up (median 11 months), 27% of patients saw a nutritionist, 6% saw a provider for a medically supervised weight loss program, and 6% underwent bariatric surgery. The median weight change was a loss of 0.6% body weight. CONCLUSIONS: In this discovery cohort, a large proportion of MFM preconception consultations lacked appropriate screening for obesity-related comorbidities. While the vast majority of consultations included a discussion of potential pregnancy complications, relatively few patients achieved significant weight loss. More emphasis is needed on weight loss resources and delaying pregnancy to achieve weight loss goals.

via The Well-Rounded Mama