When a seven-post series entitled Maternal Obesity from All Sides started making its way around the blogosphere I was immediately intrigued. Kimmelin Hull is the woman behind this huge undertaking and I’m honored she carved out time within her busy schedule for the interview you’ll see below.
Kimmelin is a Lamaze Certified Childbirth Educator, Physician Assistant, American Red Cross First Aid/CPR instructor, writer, and somehow balances all of those roles while being a wife and mother to three children. She just completed a poignant book called A Dozen Invisible Pieces and Other Confessions of Motherhood and writes a fantastic blog called Writing My Way Through Motherhood and Beyond.
What compelled you to write the Maternal Obesity from All Sides series?
Maternal obesity is a “hot topic” right now in the maternity care provision and research industries. More and more negative clinical outcomes are being tied to this scenario—some that seem legitimately problematic, others that seem like an unfair accusation of responsibility upon pregnant women of size. I wanted to look at the issue from multiple viewpoints: from that of the clinician, the researcher, the childbirth educator and a woman of size. In some cases, the perspectives represented in the series are those of women who fulfill more than one of the above roles.
This is a quote from your first post within the series, “The problem with using BMI as a body weight categorization tool, is that it does not take into account bony structure, muscle mass or percentages of lean mass compared to adipose tissue. At best, Body Mass Index is a crude measure of health.” As a physician assistant with all of your clinical training what made you come to this conclusion when most of your peers use BMI as a standard practice of care? On a side note I became your #1 fan after reading your views on BMI!
If you really look at it, BMI is just that—a crude measure that doesn’t take into account muscle mass, body fat percentage, bony structure, etc. Consider a 5’0” woman who weighs 100 pounds, smokes a pack a day of cigarettes, and doesn’t exercise: she may have a very low BMI (19.0) that’s considered “normal” by BMI charts—but that doesn’t mean she is healthy. Consider a woman who is 5’5” and 150 pounds, is an avid athlete and weight lifter, eats extremely healthfully and doesn’t smoke. Her BMI is 25—placing her in the “overweight” category and yet, she may have an incredibly low body fat percentage depending on her muscle mass due to weight lifting, and be extremely healthy by all other measures.
In part two of your series, you gave two examples of how a care provider could counsel a woman diagnosed with gestational diabetes. The first example ended with a threat of possibly not being able to vaginally deliver a baby. Within the second example, supportive resources are offered to help a woman control her blood sugar. From the comments I've seen on Plus Size Mommy Memoirs (PSMM) Facebook page most plus size women are berated with your first example. Sadly a lot of PSMM mothers have shared stories of being mistreated by medical professionals due to their size. You mentioned throughout the series the importance of upholding a woman’s dignity while providing her care. What can be done to increase the odds that an empowering and positive conversation will take place with a care provider?
Well, I think it starts with choosing your health care provider carefully in the very beginning. Perhaps starting with obtaining recommendations from family/friends/co-workers of HCPs in your local area with whom others have experienced compassionate, evidence-based care that focuses on a teamwork approach is a great place to start. There will be a time for just about all of us when we will receive information from a healthcare provider which we’d rather not hear. If we’ve already established a strong, healthy rapport with that provider—and trust that their advice is delivered with equal amounts of compassion and best evidence-based knowledge, then we may find ourselves more willing and able to act on that information in a collaborative way. I think in most cases, even when a provider has less than positive news to deliver, a positive approach can still be outlined to help the patient/ consumer/individual take steps to optimize their health.
In part three of the series you talk about an action plan for helping women to obtain a healthier weight before getting pregnant. One of your suggestions is the following, “Implementation of healthy body weight discussions at every well-woman exam appointment. This might include discussion of individualized genetic risk factors and socioeconomic issues that add a greater degree of challenge to the woman’s overall scenario.” I think this does happen but not often enough. Do you think, as our obesity rates continue to climb, that some of your suggestions will actually come to fruition? Kristen Montgomery also had some great suggestions within the fourth post of this series.
The best answer I can offer is, “I hope so.” The good news is that more and more research dollars are being poured into looking into the obesity epidemic and its various ramifications and sources. That being said, comparing a person’s body weight or BMI with their disease status and various health outcomes is not enough. This really is a public health issue—not just an issue that the American Heart Association, American Diabetes Association, etc. ought to approach in isolation. It is so multi-faceted including issues like genetic inheritance and epigenetics, nutritional knowledge, financial burden and time constraint issues.
Here’s an example scenario: A single mother working two minimum wage jobs to feed her children may not have the time to cook healthy meals, nor the money to buy optimally healthy food. She may opt for picking up high calorie, high saturated fat, fast food for dinners on her way home from—or in between—work more often than not. “Fruit” may consist of the less expensive option of a few slices of canned peaches or pears in heavy syrup rather than a piece of fresh fruit. Vegetables may come from a store that offers low prices, but sells second and third-pick produce. Children exposed to this model of less-than-optimal nutrition grow up to be adults who conceptualize nutrition in the same way—and pass this knowledge onto their offspring.
I've been a fan of Pam Vireday's writing since I found her via www.plus-size-pregnancy.org when I was pregnant. What was it like working with her and reading her views on plus size pregnancy and birth?
Pam was great to work with. She is so diligent in researching news stories and journal articles that pertain to plus-size pregnancy. She calls the literature out on the carpet when the data suggest one thing, but the research summary or abstract say something different. I approached this series wanting to have an open, inclusive mind set, and she pushed me to maintain that openness.
What stood out to you the most once you completed this insightful project?
I think that while many of us (some of us?) want to find a way to: reduce the types of obesity that lead to real clinical problems; reduce the numbers of iatrogenic clinical scenarios that occur, using obesity as an excuse; and also treat people of size with the compassion and dignity they deserve…there are still some big disconnects out there. In some scenarios, people of size are just plain treated wrong—all because of their weight (pregnant women of size undergoing increased number of c-sections is a great example). In other cases, it seems that people of increased weight want to be left alone no matter what, that they don’t want to accept information that does irrefutably point to associations between weight and ill-health (obesity and heart disease, obesity and type two diabetes, for example). There’s got to be a way to bring everyone to the table.
In short, I think we’ve got to be honest with ourselves and each other. Medical providers recommending treatments and interventions to their obese patients which are not evidence-based need to look within themselves and ask the hard question, “Why am I doing this/offering this? Is it because I really think this treatment/intervention will improve this person’s state of health? Or is it based on some internal bias I am harboring?” If the answer is yes, the treatment/intervention is likely to improve the patient’s state of health, then the next question to be answered is, “How can I make the recommendation in the most compassionate and empowering manner?”
A great example of this comes out of the field of orthopedics: An extremely obese patient might seek help by an orthopedist for her bilateral knee pain:
Patient: “Doctor X, my knee pain is so severe, I can hardly get out of bed in the morning. Doctor X: “After completing your examination and reviewing your x-rays, I can tell you that you have severe degenerative arthritis in both knees and that you would benefit from bilateral knee joint replacements. But I’ll only do the surgery for you if you lose fifty pounds, first. Come back and see me after you’ve lost the weight.”
It may be clinically true that the woman will achieve a higher rate of success following her knee surgery if she lost some weight, but this is not a terribly empowering, collaborative approach to the problem. Instead, the doctor might approach the scenario this way:
“After completing your examination and reviewing your x-rays, I can tell you that you have severe degenerative arthritis in both knees and that you would benefit from bilateral knee joint replacements. I’m going to set you up with appointments with our physical therapist and nutritionist who can help you map out a plan for safe, healthy, weight loss and pre-surgical exercises that won’t aggravate your knee pain. Let’s check back in with each other in three months and see how it’s going.”
Likewise, people of size—in this case, women of size—might also benefit from asking those painfully honest types of questions, and considering where they might be able to make changes. I’m not suggesting this is easy on either side of the fence: changing our genetics, our lifestyles, or beliefs and our circumstances can be very difficult, and can take a lot of time. Likewise, changing medical and/or maternity care practices are also clearly difficult and can take a lot of time. History has proven this to us again and again.
Do you feel as if the question you asked in the beginning, “How do we tenderly care for these women, employ evidence-based practices, and still support and honor normal birth whenever possible?” was answered?
Yes, I think so, between the various posts done by myself and the other three authors. There really are not very many circumstances in which normal birth* becomes more dangerous than medically intervened birth—even for women of size. And we all know that when those statistically rare circumstances do occur—hemorrhage, extreme hypertension, placenta abuprtia, for example—we are more than poised to handle them in the majority of maternity care units (in the U.S., at least.) Although women’s and babies’ bodies differ greatly, the basic mechanics of birth are pretty much the same across the board. How we approach each woman is where the variability comes in.
*normal birth=birth that is properly encouraged and supported, such as according to Lamaze’s Six Healthy Birth Practices
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