Junkfood Science: Calling a spade a spade

April 30, 2007

Calling a spade a spade

Countless numbers of fat people have been denied treatment by their doctors until they lose weight. Some of the cruelest cases I’ve seen have been in patients suffering excruciating pain and disability from genetic crippling arthritis that’s destroyed their hips or knees. These patients were left to suffer because their doctors said they didn’t want to “waste” a hip or knee replacement on them. They were denied the pain relief and return to functional living simply because they were fat.

Unlike here in America, when this happens in Britain, it makes the news. A controversy that’s been raging there since 2005 — when the East Suffolk primary care trusts stopped funding joint replacements for patients unless the patient has a body mass index (BMI) below 30 — has again reared its ugly head. The Daily Mail reports:

Millions in danger of being deemed too fat for NHS surgery

Millions of patients could be denied some NHS treatments because they are overweight or smoke. The controversial policy has already been adopted by around one in ten hospitals - many of them battling to claw back huge cash deficits.

Health Secretary Patricia Hewitt has stirred the row further, saying a ban on surgery to replace problem joints is "perfectly legitimate". Doctors say the risks of operating on obese patients are higher and the treatment may be less effective, with new hips and knees wearing out sooner....

But the spread of the policy has brought angry protests from obesity experts, Opposition MPs and patient groups. They say patients are being denied treatment to save money, rather than on clinical grounds, and point out that problems with joints can often be a reason for obesity, as sufferers cannot exercise....

A survey of 116 primary care trusts found that nine are refusing joint replacements to obese patients and four have blocked orthopaedic surgery for smokers. The trusts, which cover six million patients between them, are almost all heavily in debt....Health trusts in Suffolk were among the first to say that obese people would be denied hip and knee replacements as part of an attempt to save money.

In the most bizarre argument, one doctor said BMI shouldn’t be used to rule out surgery, but waist circumference should, as if there is any evidence that hour-glass figures have less joint impact. The article concludes with cautionary notes about other discriminations such initiatives could lead to:

Joyce Robins, co- director of Patient Concern, said: “A national health service should not be deciding on who is worthy of treatment. This is a slippery slope. Do we next decide that those with criminal records should be denied healthcare? “These people have paid into the system all their lives. They will find it hard to understand why they must pay for someone to have their fourth child or for those who injure themselves in dangerous sports while they are excluded from the service.

“It may help trusts balance their budgets but could cost society far more. Deny a much needed new hip and the patient will become crippled and the cost of caring for them will soar. It makes no sense."

As the Telegraph reported today, nine NHS primary care trusts, which provide care to 6 million people, are refusing to give joint replacements to patients who are obese:

"That is a perfectly legitimate clinical decision. I support doctors making clinical decisions in the interests of their patients." Miss Hewitt's comments come amid growing calls for the NHS to take a tougher line on heavy smokers and the seriously overweight. Last summer, a survey found that two in five hospital doctors believed that smokers should pay for bypass operations.

But Andrew Lansley, the Tory health spokesman, said: "Trusts shouldn't have a policy which excludes people from treatment because they either smoke or are overweight, because treatments should be based on clinical needs."

It appears that the opposition over the 2005 Trust’s decision has gone unnoticed. A Cambridge doctor had written in the December 17th issue of the British Medical Journal:

The decision of the East Suffolk primary care trusts... breaches basic principles of health care that do not seek to judge patients for their illness....No evidence supports withholding joint replacement from obese people, even on utilitarian grounds.

A UK health technology assessment of hip replacement concluded that obese patients ... did not noticeably increase the operative risk. Chan et al found no significant difference in the improvement in scores (of quality of life) between the non-obese and obese groups, concluding that relative body weight alone does not influence the benefit derived from primary total hip arthroplasty.

Since obesity does not increase the risks or diminish the benefits of joint replacement, the trust's decision to deny such treatment seems to be based on prejudice or attribution of fault, or both. Logically extended, such a policy would deny treatment to, among others, smokers, most patients with HIV infection, and those who sustain sports injury.

And a Gloucesterhire doctor wrote:

Delaying operations on “punitive" grounds may increase long term costs. Personal experience shows that delaying joint replacement surgery causes deterioration of functional capacity, which is difficult or impossible to reverse after later operation. What is the evidence that these strict conditions are not in the longer term damaging?

This is rationing by any other name.

Joint replacement surgeries are soaring worldwide and it’s become popular to blame obesity. The American Academy of Orthopedic Surgeons reported last month that total knee replacements among ages 38 to 56 has doubled here in the past ten years, according to a Los Angeles Downtown News story. But, in contrast to beliefs that they’re mostly due to fat people, the AAOS said: “Many of these younger patients are athletic types who sustained injuries in their 20s, or are people who continue to indulge in high impact sports.” Otherwise, these surgeries will likely become more common as the prevalence of arthritis increases as the general population ages. An Australian surgeon at Brisbane Orthopaedic Specialist Services, estimated that 90 per cent of the 30,000 joint replacement operations in Australia are because of osteoarthritis. “There is an increase of people under 50 having the operations,” he said. But it isn’t because of obesity. It is “because of an increase in competitive and contact sports and also high- impact activity,” he said.

But misconceptions go far beyond pointing fingers, it affects the treatment people receive. Don't people rightly deserve medical care that’s based on credible science and quality medical research, not colored by bias?

The belief that fat people don’t deserve joint replacements because these surgeries are less successful and a “waste” on them is widespread, but is not well-founded. The fact such a belief perpetuates despite the enormous amount of evidence against it calls for health care professionals and public health officials to do some very deep soul-searching.

The evidence isn’t just found in a few outlier studies, but in the bulk of them. While this review is by no means all-encompassing, it will hopefully help open eyes as to how much preconceived prejudices can blind us to contrary evidence we don’t want to see. And when instances of unnecessarily poor outcomes are found at certain centers, hopefully the first response will be to examine the quality of care and not just blame the patients. I also hope that this information will benefit fat people when they encounter such discrimination to realize equitable care includes them.

How do the “obese” fare after joint replacement surgeries as compared to “nonobese?”

A 2002 study of 180 total knee replacement (TKA) procedures in the Journal of Arthroplasty looked at how body weight affected one-year outcomes and reported that “body weight did not influence adversely the outcome of TKA.

A longer-term study following patients for an average of seven years was conducted by researchers at the Department of Orthopaedics, Johns Hopkins University School of Medicine in Baltimore, Maryland, reported: “There were no significant differences in the combined percentage of good and excellent results between the two groups. On the basis of the results of this study, it is believed that weight as a factor by itself should not compromise the ... results of total knee arthroplasty.

Here in the U.S., the Agency for Healthcare Research and Quality (AHRQ) under its Evidence-based Practice Program recently examined the evidence on TKA procedures, the most common orthopaedic procedure performed. They noted that it had previously been established that the evidence supports these surgeries because they improve functional status, relieve pain and result in relatively low perioperative morbidity. For this NIH report, the AHRQ was especially interested in determining who is most likely to benefit and in what patients the procedure may be contraindicated. Their conclusion: “Age, obesity, or gender do not seem to be significantly correlated with TKA outcomes.

Do things other than clinical data influence who gets these surgeries or in treatment delays? The AHRQ report found “lower rates of TKAs among blacks despite a higher prevalence of osteoarthritis in this group.” They found “the evidence regarding non-white groups is quite consistent. Non-whites receive TKAs about half as often as whites.” And a Canadian study looking at the equitable nature of waiting lists reported that while there were no biases in waiting times for joint replacement surgeries with respect to age, gender, education or work status; there were in other respects. Waiting time was determined by the patient’s body mass index and the primary language they spoke, as well as marital status.

While it is believed that the surgeries won’t last as long and need more revisions in the obese, this isn’t necessarily the case. Researchers at the University of Utah, Salt Lake City, published their study of 840 hip and 911 knee joint replacement surgery patients, aged 55 to 74 years, in a recent issue of the American Journal of Preventive Medicine. They also found “no statistically significant association was found between obesity and the risk for hip or knee revision procedures.”

And a ten-year follow-up study of TKAs performed on 22 obese patients and 34 nonobese patients at the Complete Knee Center of Arkansas, Van Buren, found that while stair climbing was more difficult among obese post-op patients, overall, “10-year Hospital for Special Surgery scores and Knee Society scores for patients who were obese were comparable with scores for patients who were nonobese and given lower preoperative Hospital for Special Surgery scores, improvement in knee score was greater. Revision rates in patients who were obese were not higher than in patients who were nonobese at 10 years follow-up.”

Addressing the specific question as to if obesity is contraindicated because of surgical complications, researchers at the University of Arizona, College of Medicine in Tucson examined 405 primary bilateral TKAs done under one anesthetic for incidences of wound infections and systemic complications. They found: “Preoperative and postoperative knee scores were not significantly different for any patient group. Local wound complication rates did not differ between any of the study groups.... there was no significant difference in complication rates between patients with obesity who underwent unilateral or simultaneous bilateral total knee arthroplasties. Based on these findings, obesity does not seem to be a contraindication to bilateral total knee arthroplasties under one anesthetic.

A retrospective examination of complications for the two years following joint replacements in 130 obese and 51 nonobese patients at Lutheran General Hospital in Park Ridge, Illinois, concluded: “The hospitalization time, number of days with a fever, number of transfusions, preoperative and postoperative hemoglobin levels, and days requiring intramuscular narcotics were very similar between the two groups. There were 0.29 minor complications per nonobese patient, but only 0.22 per obese patient. Major complications were encountered 0.22 times per nonobese patient and 0.10 times per obese patient. The patient is not necessarily at a higher risk for perioperative complications in total joint arthroplasty.”

As the AHRQ noted, function and quality of life can greatly improve after a joint is replaced. This benefit is shared equally among fat and thin. A study of TKAs performed from 1989 and 1994 by University Orthopedic Specialists in Tucson, Arizona, reported: “Knee prosthesis and functional scores improved statistically after TKA.” Among the patients who had limited functional capacity, the most common cause was “progression of their arthritis at other sites, especially lumbar spine and hips, and cardiopulmonary problems....[but] Patient weight, body mass index (BMI), and age at surgery showed no correlation with postoperative functional scores.”

A study published in Obesity Research examined one-year outcomes among 592 primary total hip arthroplasty patients and 1011 primary TKA patients. It concluded: “Obese patients enjoy as much improvement and satisfaction as other patients from total joint arthroplasty.”

If our goals as healthcare professionals are to help improve the lives of patients, don’t all patients deserve that — not just the ones whose bodies it's popular to think are more fitting?

© 2007 Sandy Szwarc

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