Why Your Orthopedic Surgeon Is Not Fat-Shaming You It’s Not About Fat Shame—It’s About Fat Facts

By 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 femoral epiphysis.

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

After surgery:

• 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

In spine 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.

In 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:

• Ellen Gordon, MFT www.ellengordonmft.com
• Rachel Liger, RD www.appetitefocusedweightloss.com
• And a helpful resource: Binge Eating Disorder Association - www.bedaonline.com

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 your life.

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.)

⁴ (Spine: 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.)