Please stop talking to my patients about their BMI.

Pelvic Health and BMI. I grew up as an orthopedic/sports medicine physical therapist. If I had a dollar for every patient (male and female) I have treated in my 23 years as a PT who was told by their medical provider that weight loss would get rid of their low back or knee pain….I wouldn’t be rich, but I would’ve paid off my student loans a lot faster. My response to my patients then and now is the same. Weight loss isn’t an immediate solution for your symptoms, I am not sure I believe that is how or why your symptoms started-let’s figure the real why out instead, and we have solutions that can get you better without you losing a pound. Sure enough, they got better without losing any weight. AND the relief they received allowed them to return to fitness activities that contributed to weight loss that might affect their cardiovascular or diabetic risk factors.

Flash forward to now and the last 16+ years of combining sports medicine with pelvic health, and my patients are still hearing about weight loss as a solution for their symptoms. This time it is related to their risk for and experience with incontinence and pelvic organ prolapse. My experience with this is the same, I can get folks better without them losing an ounce. Either I am that good a therapist or BMI may not be the risk factor we think that it is for both pain and pelvic health. I tend to think it is the latter.

June is Prolapse Awareness Month

Last June I wrote an article asking questions and expressing concerns about the circulated statistic that women have a lifetime risk of 50% that they will experience pelvic organ prolapse (POP). You can read it here. One of the articles I was sent to support the 50% statistic was about the prevalence of POP in overweight and obese women, which is a specific population and shouldn’t be universally applied to all. Women, who consider themselves overweight if they are still carrying 5 extra pounds after delivery, hear that relationship and assume that is why they have POP or could get POP. It’s not. It doesn’t explain POP or incontinence in the fit population I treat. We have to be super careful how we share information and who we are targeting with that information. Social media is already littered with weight loss messaging, before and after pics, diets, and unhealthy body image info. Stop!! I feel really protective of my mama’s hearts.

Having said that, it has been a long held understanding that being overweight or obese is a correlated risk factor for incontinence and prolapse. However, I wonder if we have been looking at those stats upside down.

So let’s look at a few studies… incontinence first

A systematic review by Hunskaar (2008) noted that a rise in BMI was associated with a rise in the rate of incontinence and incontinence severity (BMI is calculated by dividing your weight by the square of height). 18.5-24.9 is considered the range of normal or “healthy” (average risk of co-morbidities). While >25 is considered overweight (some increased risk of co-morbidities), and >30 is considered obesity level I (moderate increased risk), >35 is obesity level II (severely increased risk), and >40 is obesity level III (very severely increased risk). While prevalence went up with each tier, one study Hunskaar reviewed indicated that the majority of symptoms were mild.

In order to get to this statistic and relate it to being overweight and obese, the authors must limit the other potential variables that could have created a change in their POP status from age to smoking to hormones to surgeries or other injuries. This means they can only draw conclusions around relationships in the data, versus saying that incontinence was caused only by a high BMI. This means other variables need to be considered, too. It was also noted in some of the data reviewed there was a stronger association with higher BMI and stress incontinence (SUI) vs. urge incontinence. This is an interesting clue to me on other ways we can draw conclusions around the data and intervene (keep reading to the end to connect this dot).

Now prolapse….

Similarly, prolapse prevalence has been shown to increase with weight gain. Kudish et al (2009) observed weight gain over a 5-year period in women ages 50-79 (again a specific population, and not the demographic that much of social media messaging is targeted at), and noted a correlated increase in prolapse over that same time period in a large sample size. But let’s break that down a bit. Kudish et al (2009) included in that statistic women who had a grade 1 prolapse, which we are now considering in the range of normal.

There was no information in the study on whether or not those women had symptoms related to the prolapse. We are beginning to use language like symptomatic and asymptomatic prolapse, to distinguish severity and to try to understand the nature of a diagnostic finding and how or if that creates bother for a patient. This is very much in line with what we are talking about in the realm of pain (also known as pain science). We know understand that an MRI showing a herniated disc doesn’t always mean folks have symptoms. Same goes for heels with bone spurs, knees with arthritis, shoulders and hips with cartilage damage (see this graphic). I wrote a blog about applying these ideas to the issue of prolapse over four years ago (you can read it here: What is the Goal of Prolapse Rehab?).

Here is one more kicker…Kudish et al (2009) noted that a 10% weight loss did not improve POP status. In fact, they observed a “surprising” mild borderline worsening of uterine prolapse with the weight loss. Hmmm…..The authors conclusion was that the damage done to the pelvic floor by the weight was irreversible. Wait, what? NO. They made that conclusion without any known effort to reverse and/or actively treat the prolapse as far as I could surmise in the study. SERIOUSLY. SO. MUCH. FEAR. Stop freaking out my mama’s.

Here is the other thing that both of these groups of patients are told. Hurts when you exercise? Leaking or prolapse symptoms when you exercise? Stop doing that. Wait, what? It is a catch-22. The medical model encourages weight loss as a solution, while simultaneously eliminating an opportunity for fitness to be a component of the weight loss plan. In addition, without fitness cardiovascular, bone, emotional, and social health can be compromised.

How about an alternative interpretation to consider?

We continue to broadened our understanding in pelvic health to look beyond just the status of the pelvic floor to help address pelvic health issues. Movement, muscular relationships and pressure systems work together to help us pull off continence and protect pelvic organs. Pelvic health isn’t understood as a one muscle achievement anymore. Movement and fitness can activate, enhance and promote the efficient and balanced work of all of those muscles and pressures to promote pelvic health.

The upstream impact of an integrated fitness approach that involves the pelvic floor and the dynamic support and interrelationship of other musculature and pressures then becomes a positive downstream prevention tool for both incontinence, prolapse and for managing BMI. This also changes the focus of the problem.

Rather than indicate that incontinence or prolapse are the result of high BMI, could it be that a lack of fitness may be a contributing factor to all three? If exercise and movement are protective of pelvic health (and I think that it absolutely can be, could be, are, should be, and do protect it) and the overweight and obese populations aren’t actually exercising are they experiencing pelvic health symptoms simply because of a lack of exercise? Something to ponder. Or was the SUI present prior to becoming obese and they limited their fitness because of it leading to their weight status? Is it that added weight requires extra effort to lift up from a chair and results in a breath hold to pull it off? Breath holding is a high intra-abdominal pressure strategy which is a known trigger for stress urinary incontinence (SUI). So leaks as they get up from the chair may be related to high intra-abdominal pressure versus the actual weight creating the problem. (Please connect the dot with the comment above that SUI was more common than urge incontinence with weight gain).

You can use the teamwork of all those muscles and breath to reduce your intra-abdominal pressure as you get out of a chair to eliminate leaks at any weight. OR you can hold your breath and struggle to get out of the chair at any weight and experience a leak. The former strategy eliminates leaks, helps you get out of the chair and uses that functional activity to train the movement and continence system connection. We can link that system in and through fitness too. After all moving from sit to stand is essentially a squat.  

Let’s help women keep moving as an important part of their long term health picture, this includes their pelvic health. This is in contrast to eliminating fitness as a “solution” to their pelvic health or pain issue, particularly if we are also telling them they just need to lose weight to solve the problem. Is a lack of exercise over time the cause of dysfunctions in pelvic health and BMI is only another symptom? Let’s flip the conversation, strive to promote healthy activity and consider looking at this and the stats a little differently.

Mama Bear out.

PS Can we just stop talking about BMI as a measure of fitness, too. It is still a component of school fitness testing here in California, and kids cannot complete their high school PE requirement if they do not achieve 6 out of 7 categories of fitness. One of the categories is BMI in an age corrected healthy category. Sorry, but that is ridiculous. I looked up the top 10 female Crossfitters aged 35-39. Technically their sport is fitness, and Games athletes compete for the title of fittest man or woman in the world. Among the top 10 female competitors, 3 had BMI’s that classified them as being overweight. 2 had BMIs at the upper end of healthy above 24, 3 were above 23, and the final 2 were above 22. We gotta change the game and conversation here folks.

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References

Hunskaar, S. (2008). A systematic review of overweight and obesity as     risk factors and targets for clinical intervention for urinary         incontinence in women. Neurourology and Urodynamics, 27(8),  749-757. doi:10.1002/nau.20635

Kudish, B. I., Iglesia, C. B., Sokol, R. J., Cochrane, B., Richter, H. E., Larson, J.,       … Howard, B. V. (2009). Effect of weight change on natural history of    pelvic organ prolapse. Obstetrics and gynecology, 113(1), 81–88.          doi:10.1097/AOG.0b013e318190a0dd