Frequently Asked Questions: Orthopedic Concerns

Also See FAQS:  Calorie Monitoring

Dr. Bacon,

I enjoyed your piece on weight loss vis-a-vis longevity. [Referring to article entitled End the War on Obesity: Make Peace with your Patients.] As an orthopedic surgeon my concerns are more with increased wear on weight -bearing joints and joint replacements. How does this affect your recommendations? I don’t really enjoy trying to force weight loss on prospective TJR candidates but the ortho literature enforces that approach. Any thoughts for me?

David Heller, M.D., South Weymouth, Massachusetts

Dr. Bacon’s response:

Joint issues are one of the exceptions where a causative mechanism is more evident. But it may not be as clear cut as we think. The rationale, of course, is that the heavier you are the more stress you place on weight-bearing joints. However, the fact that heavy people with arthritis also frequently have arthritis in their wrists suggests that the connection is more complicated than we presently understand. (I’ve also been intrigued when considering a related issue – that the same stress on the bones also confers an advantage: heavier people have reduced risk of osteoporosis.)

But nonetheless, even though there is likely a causative factor involved and weight loss may be helpful in reducing symptoms, my advice would be no different. We don’t have a clue how to help people to lose weight – there is certainly no research to substantiate that any method is effective. (As much as we’d like to believe that consciously manipulating the old calorie balance equation does the trick, it just isn’t proving true!) And there’s certainly extensive evidence to show that prescribing weight loss is damaging.

So my first bit of advice is that you give the heavy person the same suggestions you would give to someone slender. Appropriate exercise? Meds? Surgery? Then do what you can to support them in implementing your advice and handling the challenges posed by a larger body. For example, you may have to be more creative in suggesting ways to get more active. That includes the issue of what types of movement you prescribe in addition to problem-solving how to overcome barriers to exercise. (Example: a slender person out for a run or at the gym gets support and encouragement; a heavier person trying those same things is often subject to ridicule. This makes it harder for the larger person to implement your advice.)

So I see that as your task to best help your patients: learn more about how to support people being functional in their larger bodies.

And of course, if you suspect improved eating habits is warranted, I would suggest a referral to a health care practitioner who specializes in this. (But I’d be wary of making this assumption based on size; many thin people can benefit from this advice as well, and not all heavy people have a problematic relationship with food.)

It is possible that if your patient has poor health behaviors, weight may change as a side effect of improved behaviors, making this a helpful adjunct to your treatment. But I also want to encourage you to be open-minded regarding weight outcome. Though it seems like common sense that weight loss should be a side effect of improved health behaviors, this isn’t always true. Mechanisms for weight gain are very different than weight loss, and reversing bad habits doesn’t always result in weight loss – though it will result in health improvement.

Best wishes in your work and glad to hear of your open-mindedness to Health at Every Size.

And back to Dr. Heller:

It is absolutely wonderful and delightful to finally hear someone speak about weight with such commonsense and clarity. Having sat with many an overweight patient desperately in need of knee pain relief, having performed many knee and hip replacements in such patients and then enjoying watching them become happy once the pain is relieved, and seeing them increase their activity level, has given me great satisfaction as an orthopedist. I always suspected that the establishment was overstating the importance of weight with regards to the risks of surgery, particularly in orthopedics. So, I commend you and thank you for your thoughts and stance on this issue. I now feel I can speak better at our conferences when this discussion comes up in the future.

Dr. Bacon replies again:

Now get yourself over to the Fat-Friendly Health Professionals list and sign yourself up, Dr. Heller. There are countless heavy people with joint problems who have been mistreated by orthopedists or fear seeking treatment and getting the “lose weight before I can help you” lecture. Glad to have you as an ally. We need more caring, competent physicians!

Linda Bacon, PhD on Facebook & Twitter Like on Facebook Follow on Twitter @LindaBaconHAES


The HAES Book

Health at Every Size: The Surprising Truth About Your Weight (HAES) has revolutionized how we think about weight, fitness, and what "health" really means.

The sequel, Body Respect


Body Respect: What Conventional Health Books Leave Out, Get Wrong, or Just Plain Fail to Understand about Weight is the insider’s guide not just to nutrition and our bodies, but to all that’s misunderstood about them.



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