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Year : 2019  |  Volume : 2  |  Issue : 1  |  Page : 50-53

The Surprising Effect of Body Mass Index on Elective Orthopedic Surgeries

1 Department of Rehabilitation Medicine, Emory University School of Medicine, Atlanta, Georgia, USA
2 Department of Biology, Georgia State University, Atlanta, Georgia, USA

Date of Web Publication22-May-2019

Correspondence Address:
Dr. David T Burke
Department of Rehabilitation Medicine, Emory University School of Medicine, 12 Executive Park Ne, Atlanta 30329, Georgia
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jisprm.ijprm_12_18

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Elective orthopedic surgeries are often deferred or declined due to concern about the patient's elevated body mass index (BMI). The study team conducted a literature review of studies focusing on the relationship between BMI and outcomes of elective orthopedic surgical procedures. The literature review found that overweight and obese patients have similar gains in function and pain reduction as do patients with normal weight, with adverse perioperative outcomes more evident in the higher levels of obesity. These data suggest a need to review the current policies concerning surgical eligibility based on BMI. These data suggest that restrictions of surgical procedures based on BMI may be too restrictive and should be revised based on the current literature.

Keywords: Body mass index, obesity, orthopedic, outcomes, surgery

How to cite this article:
Burke DT, Bell RB, Burke DP. The Surprising Effect of Body Mass Index on Elective Orthopedic Surgeries. J Int Soc Phys Rehabil Med 2019;2:50-3

How to cite this URL:
Burke DT, Bell RB, Burke DP. The Surprising Effect of Body Mass Index on Elective Orthopedic Surgeries. J Int Soc Phys Rehabil Med [serial online] 2019 [cited 2023 Mar 27];2:50-3. Available from: https://www.jisprm.org/text.asp?2019/2/1/50/254173

  Introduction Top

According to the World Health Organization, overweight and obesity has a prevalence of 1.9 billion and an annual mortality of 3.4 million adults.[1],[2] The current body mass index (BMI) categories in the United States (US) were established in 1998 when the National Institute of Health lowered the overweight BMI threshold from 28 to 25 kg/m2 to be consistent with international recommendations.[3] BMI categories are calculated as the weight in kilograms divided by height in centimeters squared (kg/m2). The categories include: <18.5 kg/m2 (underweight), 18.5–24.9 kg/m2 (normal weight), 25.0–29.9 kg/m2 (overweight), 30–34.9 kg/m2 (obese Class I), 35–39.9 kg/m2 (obese Class II), and 40 kg/m2 or greater (obese Class III).[4] In the US, the Centers for Disease Control and Prevention estimates that two-thirds of the population are now overweight and/or obese.[5] Given the significant disease burden and implications of obesity it is important, when advising about surgical options, to separate the long-term medical implications of obesity from the short-term and long-term surgical outcomes of patients who choose elective surgical procedures.

For this article, we focused on patients who seek advice concerning elective orthopedic procedures. To allow for a better patient-centric decision process, we focus on medical, perioperative, and long-term surgical outcome data as well as data reflecting preconceptions within the medical community and within the society at large which may influence the decision process.

  Societal Perceptions Top

Studies in the US have demonstrated that individuals with BMI in the obese categories are often viewed negatively by others.[6],[7] Andreyeva et al., in a study of discrimination based on weight in the US, found that the prevalence of this discrimination has risen by 66% in 10 years, and it is now at a rate comparable to that of racial discrimination.[7] Others have found that patients with elevated BMIs believe that health-care facilities are places where they routinely experience shaming, based on their BMI.[6],[7] The data show that those who are obese perceive that they have experienced a weight bias at their physicians' office and often, as a result, feel that their medical concerns are minimized by their clinicians. Puhl and Heuer found that 68% of obese women reported that they avoid clinical care because of their weight and 83% stated that they felt that they did not receive suitable care based on weight alone.[6]

Research into the attitudes of medical staff has supported this perception.[6],[7],[8],[9],[10] In a study by Jay et al., 45% of medical providers reported a negative response to obese patients, with 18% feeling uncomfortable during the examination and 66% reporting that they feel that treating patients with obesity is frustrating.[9] In a study by Kennedy et al., practitioners concluded that they could not spend enough time to treat patients in need of weight management and their chronic diseases.[10] This review explores the effects of BMI on the functional outcomes of patients who undergo elective orthopedic procedures of the spine, hip, and knee.

  Overall Mortality Top

Studies concerning obesity and overall mortality in the general population provide conflicting information. Some have found that, as BMI increases, so does mortality. Others differ. Flegal et al., in a meta-analysis of recent literature, found that while obesity, in total, was associated with increased all-cause mortality, those in the overweight category of BMI 25–30 kg/m2 enjoy a significantly reducedall-cause mortality as compared to those in the normal weight category.[11] It is in this overweight category that almost 40% of adult men and 30% of adult women reside.[11] The same meta-analysis found no increased mortality among those with Class I obesity (BMI of 30–34.9 kg/m2).[11] This pattern was reinforced by a prospective study of 12.8 million Koreans which found that mortality in men aged 18–34 years improved steadily as BMI increased from 23 to 25.9 kg/m2 and also improved steadily for those aged 75–99 years, as BMI increased from 25 to 32.9 kg/m2.[12] The pattern was similar for women.[12]

These data have been challenged by others, but have left us to reconsider the line on the BMI continuum at which to express an urgent need for intervention.[13]

  Surgical Intervention Top

Conventionally, adverse events, complications, and increased costs have been associated with surgeries involving patients in the obese categories. Obesity has been linked to longer operative times, increased blood loss, higher treatment costs, greater risk of mortality, and increased rates of both surgical-site infection and venous thromboembolism.[14] The association between an elevated risk of postoperative complications and obesity may be somewhat dependent on confounding variables within the obese categories.[14] When controlling for these variables, some have concluded that only persons with BMI >40 kg/m2 are at risk for higher rates of complications.[14] The current concern about the weight of patients is now reflected in medical decisions, with some clinicians restricting access to surgery based on BMI. Recently, the United Kingdom (UK) National Health Service (NHS) has begun rejecting applications for hip and knee surgery based on elevated BMIs.[15] In a study of the current practices, one-third of the clinical commissioning groups in England are now denying surgery to patients who are overweight or obese.[15],[16],[17] Under the latest recommendations, patients with a BMI of 30 kg/m2 or more will be unable to have elective surgery for a year, unless they are able to lose 10% of their body weight.[15],[16],[17]

In the US, the American Academy of Orthopaedic Surgeons (AAOS) released a position statement in 2015 recommending that patients with a BMI over 40 kg/m2 consult with their physicians about weight loss before surgery to make sure that they understand their postoperative rehabilitation requirements and whether or not they would be able to comply.[18] Under the AAOS recommendations, patients are also encouraged to sign a promise letterwhich would commit them to a lifestyle intervention of weight loss with exercise and diet.[18] This admonition suggests that weight reflects an issue of personal responsibility and reinforces the perception expressed by patients that they experience a weight-based bias. This bias has therefore, lead to a hesitation to provide needed surgical intervention, and persists despite mounting evidence that patients with obesity recover well after surgery, when allowed the opportunity.[6],[16],[19],[20],[21] In fact, the harm caused by restricting surgeries based on weight has been voiced by the UK's Royal College of Surgeons in their report,“Smokers and Overweight Patients: Soft targets for NHS Savings?”[16]

  Spine Surgery Top

Low back pain (LBP) affects 75%–84% of the population.[22] Due to incapacitation by spine injury and disease, patients often seek medical and/or surgical care for pain relief.[22] The relationship between pain and BMI has been noted in several studies.[23],[24],[25],[26] In a meta-analysis, Shiri et al. found that overweight and obese individuals are at a higher risk of LBP as compared to those in lower weight categories.[27] Smuck et al. found that the risk for LBP was 7.7% in obese Class I increasing to 11.6% for those with BMI categories of obese Class II and III.[28]

Central to the surgical restrictions based on weight are the data suggesting that patients with higher BMI have an increase in the risk of perioperative complications during spinal surgery.[29] Beyond this short perioperative timeframe, a growing number of studies have found that the surgical outcomes of many individuals in the obese categories are similar to those of patients with BMI within the normal range. Brennan et al. in a study of patients undergoing lumbar discectomy found surgical outcomes for obese patients comparable to those of normal weight patients.[30] Park et al. did not find any increased risk for perioperative complications in higher BMI patients undergoing minimally invasive spinal surgery.[31] Similar findings were expressed by Peng et al. in a study regarding perioperative outcomes with obese patients undergoing anterior lumbar surgery.[32] Chotai et al. found that obese patients undergoing elective anterior cervical discectomy and fusion surgery for degenerative cervical pathology had substantial improvements, not only with pain, but with disability and quality of life.[33]

The study also found that the surgery was economical, noting only a slight increase in cost as compared to the costs for normal weight patients.[33] Once again, a patient-centric process would emphasize both the short-term risks of complications as well as the long-term benefits of the surgery so as to offer an informed consent that would allow the patient to accept the short-term risks and gain the long-term outcomes.

  Joint Replacement Top

As an indirect measure of severe osteoarthritis (OA), joint replacement may be thought of as “terminal” OA. Some large studies demonstrate that BMI, weight, and other measures of adiposity have a linear relationship with this risk.[34] This relationship may not be as clear as merely BMI, as some subsets of adiposity measures may be of greater importance. Patients with BMIs within the obesity categories have been found to be at greater risk of perioperative complications, with some finding an increased risk of premature joint failure and revision. The final functional outcome of total knee arthroplasty (TKA) has been found to be worse in the obese than the nonobese group. However, these patients often begin at a worse functional level, with the absolute improvements found to be similar in both groups. To put this in context, Collins et al. found that after a TKA, patients in the obese categories had greater improvement in pain than those in the lower BMI categories.[35] They also found that improvements in function relative to baseline were greater among the obese than in the lower weight patients.[35] Therefore at 3 months, the patients in the obese category demonstrated greater improvement than their lighter counterparts, suggesting greater potential gains.[35]

These findings have been echoed in the writings of others. Li et al. conducted a study on functional gain and obese patients after total joint replacement.[36] Even those in the higher ranges of obesity have reported reduced pain and significant functional gains.[36] Vincent et al. reported similar findings after total hip arthroplasty.[37] Though these surgeries have a higher cost and risk, without these surgeries, the overweight/obese patients become less mobile and experience increasing pain.[38],[39],[40]

  Conclusion Top

This literature review identifies a hesitation to perform elective surgical procedures, which seems to emanate from or coincide with a societal prejudice against those who are overweight. This seems to reinforce a perception by the patients that this prejudice extends to their medical care. We demonstrate that these perceptions are substantiated in part by studies of attitudes of clinicians toward their obese patients, with data further demonstrating that patients, while likely to have significant benefits from surgery may encounter resistance or rejection by the physicians whose care they seek.

As John Adams is famous for saying, “facts are stubborn things.” The “facts” contained in this literature review may provide a database to resist a decision process that is infected with a bias based on BMI. We need to better inform the clinical decisions regarding patients seeking elective orthopedic procedures. As the data reflect a short perioperative increase in adverse events, but also a significant improvement in pain and function among those who receive these surgeries, these should be presented to the patient to allow for an informed decision process.

While obesity and health-related behaviors associated with obesity have long-term medical consequences, this paper narrows the focus to inform the decision process for elective surgery for disabling orthopedic issues. We believe that this summary outlines the rationale for rethinking a policy of deferring elective orthopedic procedures for those with a BMI higher than 25 kg/m2 and allowing a greater number of patients to receive these interventions. As we vow “primum non nocere,” we should be vigilant of the harm of omission and rethink our eligibility parameters from a patient-centric view.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

World Health Organization. Obesity and Overweight. Fact Sheet. World Health Organization. February, 2018. Available from: http://www.who.int/mediacentre/factsheets/fs311/en/.  Back to cited text no. 1
World Health Organization. Global Health Observatory (GHO) Data, Obesity. Available from: http://www.euro.who.int/en/health-topics/disease-prevention/nutrition/a-healthy-lifestyle/body-mass-index-bmi.  Back to cited text no. 2
Nuttall FQ. Body mass index: Obesity, BMI, and health: A critical review. Nutr Today 2015;50:117-28.  Back to cited text no. 3
World Health Organization. BMI Classification. Available from: http://www.apps.who.int/bmi/index.jsp?introPage=intro_3.html.  Back to cited text no. 4
Centers for Disease Control and Prevention. National Center for Health Statistics. Obesity and Overweight. Available from: https://www.cdc.gov/nchs/fastats/obesity-overweight.htm. [Last updated on 2017 May 03].  Back to cited text no. 5
Puhl RM, Heuer CA. Obesity stigma: Important considerations for public health. Am J Public Health 2010;100:1019-28.  Back to cited text no. 6
Andreyeva T, Puhl RM, Brownell KD. Changes in perceived weight discrimination among Americans, 1995-1996 through 2004-2006. Obesity (Silver Spring) 2008;16:1129-34.  Back to cited text no. 7
Puhl RM, King KM. Weight discrimination and bullying. Best Pract Res Clin Endocrinol Metab 2013;27:117-27.  Back to cited text no. 8
Jay M, Kalet A, Ark T, McMacken M, Messito MJ, Richter R, et al. Physicians' attitudes about obesity and their associations with competency and specialty: A cross-sectional study. BMC Health Serv Res 2009;9:106.  Back to cited text no. 9
Kennedy BM, Kennedy KB, Sarpong DF, Katzmarzyk PT. Perceptions of obesity treatment options among healthcare providers and low-income primary care patients. Ochsner J 2016;16:158-65.  Back to cited text no. 10
Flegal KM, Kit BK, Orpana H, Graubard BI. Association of all-cause mortality with overweight and obesity using standard body mass index categories: A systematic review and meta-analysis. JAMA 2013;309:71-82.  Back to cited text no. 11
Yi SW, Ohrr H, Shin SA, Yi JJ. Sex-age-specific association of body mass index with all-cause mortality among 12.8 million Korean adults: A prospective cohort study. Int J Epidemiol 2015;44:1696-705.  Back to cited text no. 12
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Societal Perceptions
Overall Mortality
Surgical Interve...
Spine Surgery
Joint Replacement

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