Tuesday, July 26, 2011

Framed: The Language of Media Articles on Obesity

If you haven't yet read this article analyzing the way most media articles portray obesity and the obesity epidemic, run right over and read it NOW.  Yes, it's that interesting.  Go, read.

It's called, "Morality and Health: News Media Constructions of Overweight and Eating Disorders,"  by Saguy and Gruys.  In it, they compare how news media articles from 1995-2005 frame discussions of obesity vs. discussions of eating disorders.

Here are some quotes from the article:
In the contemporary United States, thinness is associated with high social status and taken as evidence of moral virtue. In contrast, fatness is linked to low status and seen as a sign of sloth and gluttony. Drawing on an original data set of news reports, we examine how such social and moral meanings of body size inform news reporting on eating disorders and overweight.  
We find that the news media in our sample typically discuss how a host of complex factors beyond individual control contribute to anorexia and bulimia. In that anorexics and bulimics are typically portrayed as young white women or girls, this reinforces cultural images of young white female victims.  
In contrast, the media predominantly attribute overweight to bad individual choices and tend to treat binge eating disorder as ordinary and blameworthy overeating. In that the poor and minorities are more likely to be heavy, such reporting reinforces social stereotypes of fat people, ethnic minorities, and the poor as out of control and lazy.
Fascinating stuff. Discusses the moral framework the media places around obesity, and how it intersects with race and class.  The contrast with the moral framework around eating disorders really points out how media messages both reflect and shape our society's perceptions about a topic. 

If you haven't yet read this article, you should really go read it.  Go!

Thursday, July 21, 2011

Induction Triples the Risk for Cesareans in First-Time Moms

Here is the abstract of a recent study (Thorsell 2011) on how induction of labor increases cesarean rates, especially in first-time mothers with an unripe cervix.

This is yet another reason why the very high induction rate in women of size plays such a strong role in the higher cesarean rate in "obese" women.

[For example, in Abenhaim and Benjamin, 2011 about 50% of "morbidly obese" women were induced; double the 24% rate in "normal BMI" women.  In addition, more than half of the "morbidly obese" women had a very unripe cervix (dilation of 2 or less) upon admission.  Is a high cesarean rate in this group therefore any surprise?]

In the Thorsell 2011 study (abstract below), first-time mothers with an unripe cervix who were induced had a 42% c-section rate in labor.  Yes, you read that correctly; nearly half ended up with a cesarean.  After controlling for other factors, inducing labor in a first-time mother with an unripe cervix tripled her risk for a cesarean.

The effect was much less strong in multips, whose cesarean rate after induction was a more modest 14%.  Yet, after controlling for variables, their risk was still nearly doubled.  So while the total numerical rate was much lower in multips, the odds ratio was still considerably increased.

Of course, it's important to point out that induction, even in a first-time mother, results in more vaginal births than cesareans.  If you are induced, it doesn't mean that a cesarean will automatically follow; you still have a reasonable chance for a vaginal birth, especially if your cervix is ripe first or if you've had a previous vaginal birth.

But the risk for cesarean is greatly increased when labor is induced, and especially so in a first-time mother whose cervix is not very ripe.

How many of these cesareans could be avoided just by being a little more patient? 

And how many cesareans in women of size could be avoided by refraining from induction until the cervix is very ripe, or by awaiting spontaneous labor as much as possible?

Acta Obstet Gynecol Scand. 2011 Jun 17. Induction of labor and the risk for emergency cesarean section in nulliparous and multiparous women. Thorsell M, Lyrenäs S, Andolf E, Kaijser M.  PMID: 21679162

Division of Obstetrics and Gynecology, Department of Clinical Sciences, Karolinska Institutet, Danderyd Hospital, Stockholm, Sweden, and Clinical Epidemiology Unit, Department of Medicine at Karolinska University Hospital and Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden.

Objective. To assess the risk for emergency cesarean section among women who were induced to labor in gestational week ≥ 41 and to evaluate if parity and mode of induction affected this association.

Design. Hospital based retrospective cohort study.

Population: Singleton pregnancies delivered after ≥41 gestational weeks at Danderyd Hospital, Stockholm, Sweden during 2002-2006.

Material and Methods. Of 23 030 singleton pregnancies meeting the entry criteria, 881 were induced with Bishop score of < 7. Obstetric outcome was assessed through linkage with the Swedish Medical Birth Registry and a local obstetrical database containing information from patients' medical files. Results were adjusted for BMI, age and the use of epidural analgesia.

Main outcome measure. Risk for emergency cesarean section.

Results. Among women who were induced, the proportions delivered by emergency cesarean section were 42% for nulliparous and 14% for multiparous. Compared to spontaneous onset, this corresponded to a more than threefold increase in risk for nulliparous women (OR 3.34, 95% CI 2.77-4.04) and an almost twofold increase in risk for multiparous women (OR 1.94, 95% CI 1.24-3.02). There was no significant difference in risk for emergency cesarean section between the two methods of induction (PGE(2) and transcervical catheter).

Conclusion. Compared to spontaneous onset of delivery, induction of labor is associated with an increased risk for emergency cesarean section both among nulliparous and multiparous women. When labor is induced the high risk for emergency cesarean must be kept in mind.


Thursday, July 14, 2011

Taking Away the Fat Kids Again

Well, the story that consistently strikes fear in the hearts of fat parents everywhere has resurfaced again:  Should parents lose custody of super obese kids?

OMFG.  There are actually people at the Journal of the American Medical Association who are promoting this crap?  Who really believe that very fat children should be traumatized by being taken away from otherwise loving parents, simply because of weight?  Who really believe that foster care ─ where many children are abused and mistreated ─ is going to be a better environment for these children?

Here we go again, blaming the parents for their children's obesity.  Because, you know, no child could ever be that fat without their mothers actively force-feeding them deep-fried cupcakes, ice-cream IVs, and chocolate-covered french fries.*

This just ties into the popular notion that obesity is only ever about gluttony and sloth, that fat children only become that way because their parents' bad habits, and that if very fat children are just given proper nutrition they will become a "normal" weight and maintain it seamlessly for the rest of their lives.  That putting these children in a controlled environment and giving their parents nutritional lectures is going to fix everything (and won't make things worse).

In the fat-acceptance community, we've been fighting this battle for SO many years, because authorities have been periodically taking fat children away from their parents and into enforced Fat Camp Foster Care for a long time.  This is certainly no new trend; I have been in NAAFA for years and can remember cases like this going back quite a while. 

Like with most diets, the "super obese" kids in foster care lose some weight at first.....but does the program result in lasting weight loss or "normalized" bodyweights?  Not usually. But because some weight is lost for a while, the doctors and social workers and foster care system can tell themselves it worked.  Then the parents get the kid back, the kid regains the weight because that is what happens after most diets, and the parents can again be blamed for the weight.  What a vicious circle for those poor parents!  And for that poor child.

But what's really going on in these situations?  Is it always a case of ignorant, negligent, or just plain gluttonous parents feeding their children into the grave?  Or might there be more at work here? 

Even the experts who question taking away fat kids are caught up in the usual arguments; they just blame the obesogenic environment instead of directly blaming the parents:
University of Pennsylvania bioethicist Art Caplan said he worries that the debate risks putting too much blame on parents. Obese children are victims of advertising, marketing, peer pressure and bullying — things a parent can't control, he said.
I'm glad this guy is speaking up for the parents and I do think an "obesogenic" environment is relevant to some degree, but I believe he's missing an even bigger point. 

What if there are other factors at work that doctors are missing because they are so focused on only the "personal responsibility" and "obesogenic environment" arguments?

I remember one case, quite a while ago, a Giant Toddler of Doom was publicized and much ado was made about the parents and how negligent they were to "let" their child get that fat.  But this child was later found to have a genetic condition that caused him to be so fat at such a young age.  Did this fact then get publicized?  NO. The media uproar was focused on the beginning of the story, but when they later discovered the medical condition that caused this child's fatness, this fact went conveniently unpublicized. I only heard about it via my involvement with NAAFA. How much trauma was done to this young child because the doctors did not look deeply enough into his condition early on? And how much damage was done on a societal level because the media did not properly follow up on the story?

This is what I suspect in the cases of many of these "super obese" kids.  How does a child get to be 400 lbs. without something being wrong in their metabolism?  I just find it very hard to believe that a child could eat so much and move so little as to achieve that kind of weight in so little time without something being wrong.  Sure, some kids are more genetically susceptible to fatness than others, but that much?  Mightn't there be another factor at work?

Little children remarkably self-regulate their intake.  I find it very hard to believe that someone could overfeed a child to such a point of extreme fatness in so little time, even with "bad" habits like too much junk food and sweets. Remember, lots of other children in the world eat waaaaay too much junk food and sweets, yet do not become "super obese."  What makes these children so vulnerable to such fatness?

This is the problem around society's moral narratives around fatness in this country.  It lets care providers settle for the easy answers and keeps them from looking at the problem more deeply.

When doctors focus on the moral interpretations around fatness in children (the mother must be overfeeding her child, the child must be neglected or abused and is filling its emotional needs through overeating), then medical personnel conveniently don't have to look any further for biological reasons for the child's fatness. 

No onerous searches for difficult-to-detect genetic diseases or metabolic variations that might be causing (or adding to) such extreme adiposity.  Just blame it on the parents, take away the child, and ta-dah, you're done.  No messy complicating details.  And it fits what authorities want to believe about fatness.

But how many of these children really lose weight permanently under these structures?  This latest news story is careful to document several cases where the children are taken away and magically lose weight with "proper" parenting and nutrition.  But as always, the question becomes.....what is the follow-up?  If you look at only a year or two of follow-up, many weight loss efforts look successful.  It's the longer-term look that reveals the weakness of a dieting or "lifestyle change" approach and the overall harm that usually follows such approaches.

And what is the cut-off of "too much" weight, when children need to be taken away?  Who decides this?  On what basis?  And how do you weigh the potential benefit of even temporary weight loss against the tremendous trauma of being taken away from your parents?

I believe that foster care decisions should be made on the basis of other factors and not weight as the primary factor.  If the child really is being neglected or abused, then yes, take him away.  If not, but the parents really are feeding him terribly unhealthy food choices, get them nutritional help and support.  If parents are completely unresponsive, refuse to feed the kids decent food, and really are promoting terribly unhealthy practices, then look more closely ─ that kind of attitude doesn't happen in a vacuum.  Undoubtedly there is neglect happening in other ways too, and foster care can be considered on a combination of several factors. 

But take away kids from otherwise loving and caring parents solely on the basis of fatness?  No F*cking Way.  That should be fought with every breath and every fiber in our beings.

Striking Fear in the Hearts of Fat Parents Everywhere

As you might guess, this story feels very personal to me, as I bet it does to every fat parent out there. Many of us already endure the condemnation of society for daring to have children at our size, and if those children also turn out to be fat (as genetically most will be prone to do), then we suffer from the condemnation of a society that assumes that therefore we must be making them fat. 

Many of us endure the shame and stigma of frequent weight loss propaganda and lectures from doctors, school nurses, and teachers.  We live with having every item in our shopping cart analyzed by friends and neighbors and grocery clerks, and our kids' school lunches critiqued by teachers and principals.  Some have to live with BMI report cards and well-meaning but stigmatizing "obesity" programs at school.

Some of us are afraid to let our kids watch even occasional TV because we know we'll be accused of "too much screen time" making them fat....despite all the other kids we know who watch far more TV and aren't fat at all.

Some of us feel pressured to make our kids enroll in sports teams or exercise classes to show that they're fat despite getting regular exercise; sometimes we encourage them to participate even when they don't want to so we can point to their activity level and say, see, they do get plenty of exercise!

When our children gain weight and get more rounded shortly before puberty, we live with the guilt that gets heaped on us for "letting" our children get even fatter, even though "puberty pudge" is a common and natural process for many kids. 

We constantly hear news stories that blame us as parents for every ounce of our children's weight and we endure the lectures from healthcare professionals and acquaintances about the supposed "bad" habits we're teaching our kids and how to "fix" them....based more on what they assume are our habits, rather than what our habits actually are.  And we're supposed to just shut up and take these lectures or risk being labeled "uncooperative" or "non-compliant" parents.

And deep down, many of us fear that, sooner or later, someone will suggest that our children should be taken from us and put in the Fat Gulag because obviously we are doing something "wrong."  And we fear fighting back from a HAES perspective because we are afraid of being labeled "non-compliant" and giving them even more reason for taking our children away. From the above article:
In a commentary in the medical journal BMJ last year, London pediatrician Dr. Russell Viner and colleagues said obesity was a factor in several child protection cases in Britain. They argued that child protection services should be considered if parents are neglectful or actively reject efforts to control an extremely obese child's weight.
My kids are nowhere even remotely near the size in these stories, yet my first reaction to this story was still a heart-clutching moment of fear.....how long till they suggest something similar to me?  And if I fight back on a HAES basis, do I help or hurt my cause?

My eldest child looks pretty normal but qualifies as "overweight" (she wears a size 16); my second child is a very active, fit Scout and athlete but still has a little pudge around the waist; my youngest child is downright skinny (to the point of worrying about her lack of gain); and my third child is so round right now (just before puberty) that he would gain me at least a lecture and a "if he continues to gain weight" threat from some doctors.  All of them eat the same food and have exactly the same parents...but all four are on vastly different weight tracks despite similar genetics and upbringing.  How much control do we really have over our children's sizes?

I make a lot of effort to ensure that my children have plenty of fresh fruits and veggies, whole grains, healthy proteins, and exercise opportunities, but I try not to be too fascist about "bad" foods and make them the forbidden fruit kids long for, and I will not place my more-rounded children on diets in order to "normalize" their weights.  We strive for moderation and a reasonable approach, but I know it wouldn't be considered enough by the Jamie Olivers and Jillian Michaels of the world.  I screen my kids' healthcare professionals for that sort of nonsense, but what if I couldn't?  What kind of harassment and threats might I endure as a parent if I refused to put my third child on a reducing program?  Would they think I should lose custody of him?

In my saner moments, do I think it's likely that my children will be taken from me and placed in foster care because of such concerns?  My head says no because they are not even remotely near the size of the children in these stories ─ but my heart doesn't believe it.  My heart still clenches in fear every time I see one of these stories, wondering how long it will be till the cutoffs for taking away children drift lower and lower and even my children could be taken from me. 

And I wonder if the day will come when some asinine "authority" somewhere suggests we start taking away babies from fat mothers because obviously they can't be trusted to raise their children in a healthy environment.  Undoubtedly the motivations will be the best ─ to save those children from a lifetime of discrimination and supposed health issues ─ but oh my God, the trauma they will cause.

Remember, children have been taken "for their own good" from native and aboriginal peoples for a long time, and look at the havoc that wreaked on those societies.  Look at the terrible abuses many of those children suffered in the name of "improving" their lot.  Taking children away from their parents is a huge psychic wound and often has long-term personal and societal implications.

The horror stories I have heard (and seen) about some foster care situations make me terrified about what could happen to vulnerable children put into Fat Camp Foster Care "for their own good," and frankly, it makes me want to run and hide my children from the view of authorities. 

I've worked with children for many years and have seen some horrible cases of abuse. I know that sometimes children do need to be taken from their families and that many foster families do a wonderful job.....but I also know that even in those cases, such separation is often tremendously traumatic to the children.  And sadly, I also know that sometimes the place of "safety" is not always so safe, and occasionally even worse than what they came from. 

So the idea of taking fat children away from their parents absolutely HORRIFIES me, and it strikes tremendous fear in me as a fat parent.  And I bet every fat parent around the country is reacting similarly when they see that story.

Yes, we need to have some concern about children who are at such extreme weights so early in life because there can be accompanying health implications.  But is taking them away from their parents solely on the basis of weight the right fix?  I don't think so.

We must be careful that the "cure" is not more damaging than the original issue; we must not let our rights as fat parents be taken from us; we must protect our fat children from further damage by well-meaning but draconian measures; and we must stop letting society's moral narratives around fatness keep healthcare researchers from digging deeper into the mystery of these children's vulnerability to extreme weight gain. 

This story just appalls me on so many levels.

*Thanks to Meowser for that last colorful phrase.

Tuesday, July 5, 2011

Manual Rotation for Posterior or Tranverse Babies

This new study is just the latest in a series of studies that have shown that manual rotation lessens the need for cesarean during labor because of a malpositioned baby. 

In these studies, a persistent posterior baby (baby facing mom's tummy instead of her back) is turned manually to the generally-easier-to-birth anterior position (baby facing mom's back). The question has been whether such techniques improve outcomes. 

This study shows a dramatic improvement in outcomes with manual rotation.

This is a larger trial than many of the previous studies on manual rotation, which makes the findings even stronger.  This study is interesting in that it also includes manual rotation for transverse arrest (baby gets stuck facing sideways, usually as they are trying to rotate from posterior to anterior).  Not all manual rotation studies do.

Note that manual rotation is not without risks; there were more women in the rotation group with cervical lacerations, which is not fun.  However, balance that against less need for cesareans, fewer severe perineal lacerations, less hemorrhage, and less infection, and I'd say manual rotation wins, hands down.

But Should We Intervene for a "Malpositioned" Baby?

One of the controversies within the natural childbirth community these days is whether persistent posterior babies should be considered malpositions or just variations of normal, and whether we really need to intervene at all in such cases or just be more patient. 

Personally, I do believe that sometimes these positions are just a variation of normal and don't have to be a big deal.  Sometimes all that's needed is just a tincture of patience and time, and the "malpositioned" baby is born just fine.  Sometimes the baby's "malposition" is even actually needed because of a unique pelvic shape or some other factor we are not yet aware of.  So I agree─up to a point─with folks who tell pregnant women not to obsess too much over their baby's position or to feel that if they have a posterior baby that they are doomed to a cesarean etc. 

However, I think it's naive to believe that such positions are always benign and will always be born vaginally and without damage if just given enough time.  I think research is quite clear that OP labors are often harder and longer, and that there are often poorer outcomes for mother and baby

Yes, I do wish doctors would also study maternal repositioning and other less interventive alternatives so there were other options in the arsenal for a malpositioned baby.  I bet some of these babies would rotate just fine with other, less-invasive techniques, and then the more-invasive manual rotation could be used only when truly needed.   I also wish that care providers would be more patient in labors, because many positions will remedy themselves with a little extra time, or be born in that position just fine.

However, I don't believe that all malpositioned babies will be born safely "if just given enough time." Some babies and mothers will experience significant difficulties.  Many more will be subjected to forceps/vacuum extraction and cesarean deliveries, with all the associated risks. The question is whether these complications and operative deliveries could have been avoided if manual rotation had just been tried.

This new study compared manual rotation with expectant management─just waiting─and found that outcomes were significantly improved in the active intervention group.  Other studies have also found that prophylactic rotations improved outcomes. So perhaps "just waiting" is not always the best thing.

Remember, these malposition labors can sometimes be just HELL for both mother and baby. It's not always wise to wait to intervene until mother is exhausted and baby is in distress. Sometimes an earlier intervention like manual/digital rotation can be judicious and helpful. 

So while I want care providers to have more patience and use other, less invasive techniques first, I am thankful that manual rotation is in the arsenal too.  I think the results of these studies clearly show it should be learned by more care providers and applied when less-invasive techniques are not helping.

For the many many MANY of us out there who have had long hard labors and then cesareans for malpositioned babies, I say Hallelujah that care providers are re-learning this manual repositioning skill again.  About time! 

Huge thanks to the midwives and doctors who kept this technique alive when it went out of obstetric fashion.  I hope they are teaching others and spreading the word to more midwives and especially doctors.  Far too many women are being cut open because care providers don't know how to handle differences in fetal position. 

Manual repositioning can be a very valuable skill to have and will surely improve outcomes in many cases.  That doesn't mean it should be used too quickly or in place of less-interventive techniques, but that it clearly does have a place in the spectrum of options.

Shaffer BL, Cheng YW, Vargas JE, Caughey AB.  Manual rotation to reduce caesarean delivery in persistent occiput posterior or transverse position. J Matern Fetal Neonatal Med 2011 Jan;24(1):65-72. Epub 2010 Mar 30.   PMID: 20350240

Division of Maternal Fetal Medicine, Department of Obstetrics, Gynecology and Reproductive Sciences, Center for Clinical and Policy Perinatal Research, University of California, San Francisco, CA 94143-0705, USA.


To examine mode of delivery and perinatal outcomes in women with occiput posterior (OP) or transverse (OT) position in the second stage of labour with a trial of manual rotation compared to expectant management.


A retrospective cohort study was designed to examine mode of delivery and perinatal morbidity in women who underwent a trial of manual rotation (n = 731) compared to expectant management (n = 2527) during the second stage of labour with the fetus in OP/OT position. Chi-square test was used to compare categorical outcomes and multivariable logistic regression models were used to control for potential confounders.


Compared to expectant management, women with manual rotation were less likely to have: caesarean delivery (CD) [adjusted odds ratio (aOR) 0.12; 95% confidence interval (CI) 0.09-0.16], severe perineal laceration [aOR 0.64; (0.47-0.88)], postpartum haemorrhage [aOR 0.75; (0.62-0.98)], and chorioamnionitis [aOR 0.68; (0.50-0.92)]. The number of rotations attempted to avert one CD was 4. In contrast, women who had a trial of rotation had an increased risk of cervical laceration [aOR 2.46; (1.1-5.4)].


Compared with expectant management, a trial of manual rotation with persistent fetal OP/OT position is associated with a reduction in CD and adverse maternal outcomes.