Why Your Orthopedic Surgeon Is Not Fat-Shaming You It’s Not About
Fat Shame—It’s About Fat Facts
Dr. Michael Gordon
Everyone’s heard the story about the obese patient who said, “I
can’t believe my surgeon told me I was too fat to have surgery.
He spent two minutes with me, told me I was too heavy, and walked out
of the office. I felt shame and anger, and he didn’t help me at
all.” This conversation brings up some painful emotions, some difficult
issues, and some real medical concerns. Thus, I want to discuss some of
the very real medical consequences that obesity has on your health and
on outcomes of surgery. Honestly, when your surgeon weighs you in the
office, he or she is also weighing your medical-surgical risks.
As an Orange County orthopedic surgery specialist, I’m going to discuss
the following topics:
- The definition of obesity
- How obesity affect the world’s population
- The health effects of obesity
- How obesity affects orthopedic problems and surgery
- When obesity creates risks with surgery
- When obesity causes medical problems
- How does the obese patient respond to surgery compared to the normal-weight patient?
- What are outcomes in joint and spine surgery?
- The expectation that patients will lose excess weight after a joint replacement surgery
- What can be done to help me lose weight?
What Is The Definition of Obesity?
The body mass index (BMI), also known as the Quetelet index, is used commonly
to clinically define obesity. In general, BMI correlates closely with
the degree of body fat in most settings. An individual’s BMI is
calculated as weight/height2, with weight being in kilograms and height being in meters. Online BMI
calculators are available. A BMI of 30 indicates obesity, 35 – 40
indicates severe obesity, and over 40 indicates morbid obesity. A new
category, “super obesity,” is assigned to patients with a
BMI over 45. As an example, a 5’6” woman who weighs 205 lbs
has a BMI of 35, or morbidly obese. A 6’2” male weighing 305
lbs. has a BMI of 39.2 or morbidly obese. A superobese patient might be
5’8” and weigh 325 lbs.
How Does Obesity Affect The World’s Population?
Obesity is a substantial public health crisis in the United States and
in the rest of the industrialized world. Its prevalence is increasing
rapidly in numerous highly developed and developing nations worldwide.
This growing rate represents a pandemic that needs urgent attention if
obesity’s potential toll on morbidity, mortality, and economics
is to be avoided. The annual cost of managing obesity in the United States
alone amounts to approximately $190.2 billion per year, or 20.6% of national
health expenditures, according to a recent study.1
Compared with a nonobese person, an obese person incurs $2,741 more in
medical costs (in 2005 dollars) annually. In addition, the annual cost
of lost productivity due to obesity is approximately $73.1 billion2. During the past several decades, the prevalence of obesity and overweight
has increased sharply for adults in the United States. Data from 2 National
Health and Nutrition Examination Surveys (NHANES) show that among adults
aged 20-74 years, the prevalence of obesity increased from 15% in the
1976-1980 survey to 32.9% in the 2003-2004 survey.
As of 2014, 37.9% of adults age 20 years and over in the United States
are obese. 20% of adolescents and 17% of children are obese per the National
Center for Health Statistics.
What Are The Common Health Effects Of Obesity in America?
Obesity carries with it well-known and reliable health risks. There is
a greater likelihood of type 2 diabetes, heart disease (heart attack,
angina, heart failure), stroke, arthritis of the knee and hip, obstructive
sleep apnea, reflux disease, kidney failure, and some cancers (endometrial,
breast, and colon). Obesity appeared to have a particularly strong effect
among black women, with 26.8% of deaths associated with a BMI of 25 kg/m2 or higher3.
In white women, 21.7% of deaths were associated with overweight or obesity.
Among black men, 5.0% of deaths were associated with overweight or obesity,
and among white men, 15.6% were. These diseases and risk for disease diminish
as weight returns to normal in a weight loss program.
How Does Obesity Affect Orthopedic Surgery & Problems?
Obese patients have a much higher risk of arthritis of the hip and knee,
as well as a much higher risk of lifetime disability due to back pain
and arthritis and spinal stenosis. Younger obese patients have a higher
risk of deformities of the hip and knee, particularly slipped capital
When Does Obesity Become a Surgery Risk?
Even though obese surgical patients can have good results from
orthopedic surgery, they have a much higher risk of complications in the operating room and
after surgery including:
In the operating room:
- Increased blood loss
- Increased length of surgery
- Increased technical difficulty performing surgery
- Higher risk of anesthetic complications during surgery
- Increased costs
- Increased risk of wound infections and wound non-healing
- Hip or knee implant complications such as pain, loosening and infection
- Spine implant breakage and non-unions of fusion due to increased loads
- Postoperative pneumonia
- Blood clots and pulmonary embolism
- Heart attacks, strokes
- Peripheral swelling
- Lengthy recovery periods and poorer progress in rehabilitation
- Increased need for personal assistance after surgery
Morbid obesity was associated with 97% higher in-hospital complication
rates (13.6% vs. 6.9%), sustained across nearly all complication types
(cardiac, renal, pulmonary, wound complications, among others). Mortality
among the morbidly obese was slightly higher, as were average hospital
costsand length of stay.
Morbid obesity was the most significant predictor of complications in the
anterior cervical and posterior lumbar fusion groups (more than age, demography,
and other comorbidity). Both obese and non-obese patients had improvement
in preoperative symptoms, but the obese patients improved less than half
compared to the non-obese patients4.
total joint surgery:
In total knee replacements, infection occurred more often in obese patients,
with an increase of 90%. Deep infection requiring surgical debridement
was reported with an increase of 200%. Revision of the total knee arthroplasty,
defined as exchange or removal of the components for any reason, occurred
more often in obese patients, with an increase of 130% compared to non-obese patients5.
52% of total knee replacement and 36% of total hip replacement patients
were obese (body mass index ≥30). The obese patients were significantly
younger, with a higher proportion of obese total knee replacement patients
being women. Higher rates of diabetes and hypertension were found in obese
patients. Higher postoperative infection rates were observed in patients
with BMI 35 or higher.
The risk was 6.7 times higher risk for infection in obese total knee replacement
patients, and 4.2 times higher for obese hip arthroscopy patients. The
increased risk of infection in obese patients undergoing total joint arthroplasty
must be realized by both the patient and surgeon6.
What about the expectation that patients will lose their excess weight
after a joint replacement surgery?
An analysis of 3,893 total hip arthroplasties and 3036 total knee arthroplasties
demonstrated that 73% of patients who had undergone total hip arthroplasty
and 69% of patients who had undergone total knee arthroplasty
had no weight change two years after total joint arthroplasty. However, further analysis demonstrated 14% of patients had lost weight,
65% of patients had remained the same weight, and 21% of patients had
gained weight by one year after surgery for joint replacement.
After total hip arthroplasty, weight loss was associated with improved
clinical outcomes and weight gain was associated with inferior clinical
outcomes. Weight loss after total knee arthroplasty was not associated
with better outcomes, but weight gain was associated with inferior scores.
Patients who had better outcomes from their surgery seemed to lose more
weight and maintain weight loss7.
With All This Bad News, What Can You Do to Lose Weight?
One of my funniest patients, a Texas woman said, “every fat girl
out there knows exactly what she should eat and what she shouldn’t
eat, and she don’t.” Almost 90% of patients in my office with
BMI over 35
have never seen a nutritionist. Treatment of obesity starts with comprehensive lifestyle management (diet,
physical activity, behavior modification), which should include the following:
- Self-monitoring of caloric intake and physical activity (move more, eat less)
- Goal setting
- Stimulus control
- Nonfood rewards
- Relapse prevention
As with all chronic medical conditions, effective management of obesity
must be based on a partnership between a highly motivated patient and
a committed team of health professionals. This team may include the physician,
an eating disorder psychotherapist, a psychiatrist, physical and exercise
therapists, dietitians, and other subspecialists, depending on the comorbidities
of the individual patient. Scientific evidence indicates that multidisciplinary
programs reliably produce and sustain modest weight loss between 5% and
10% for the long-term8. Some professionals specializing in eating disorders:
There is so much health related science to support the link between obesity
and health problems and obesity and poor surgical outcomes. When your
surgeon says, “you are too fat to have surgery and I’m not
going to operate on you unless you lose weight,”
your surgeon is not fat-shaming you, but fat-facting you.
Your surgeon is trying to protect you by weighing risk appropriately, and
improve your chances of a good outcome. Listen to your doctor’s
suggestions – they will help you improve your health and may save
1 (Cawley J, Meyerhoefer C. The medical care costs of obesity: an instrumental
variables approach. (J Health Econ. 2012 Jan. 31(1):219-30))
2 (Finkelstein EA, DiBonaventura Md, Burgess SM, Hale BC. The costs of obesity
in the workplace. J Occup Environ Med. 2010 Oct. 52(10):971-6) and almost
$121 billion is spent annually on weight-loss products and services. (Weight
Loss Markets for Products and Services. BCC Research )
3 (Masters RK, Reither EN, Powers DA, Yang YC, Burger AE, Link BG. The
Impact of Obesity on US Mortality Levels: The Importance of Age and Cohort
Factors in Population Estimates. Am J Public Health. 2013 Aug 15.)
15 May 2012 - Volume 37 - Issue 11 - p 982–988)
5 (J Bone Joint Surg Am, 2012 Oct 17; 94 (20): 1839 -1844)
6 (Obesity and perioperative morbidity in total hip and total knee arthroplasty patients)RS Namba, L Paxton, DC Fithian, ML Stone - The Journal of arthroplasty,
2005 – Elsevier)
7 (J Bone Joint Surg Am, 2015 Jun 03; 97 (11): 911 -919)
8 ( Jensen MD, Ryan DH, Apovian CM, et al. 2013 AHA/ACC/TOS guideline for
the management of overweight and obesity in adults: a report of the American
College of Cardiology/American Heart Association Task Force on Practice
Guidelines and The Obesity Society. J Am Coll Cardiol. 2013 Nainggolan
L. New obesity guidelines: authoritative 'roadmap' to treatment.
Medscape Medical News. November 12, 2013.)