Associate Professor, Obstetrics and Gynecology, Division of Female Pelvic Medicine and Reconstructive Surgery, Washington University School of Medicine, St. Louis
Dr. Ghetti reports no financial relationships relevant to this field of study.
SYNOPSIS: Women with a body mass index in the overweight and obese range are more likely to experience pelvic organ prolapse compared to women in the normal range.
SOURCE: Giri A, Hartmann KE, Hellwege JN, et al. Obesity and pelvic organ prolapse: A systematic review and meta-analysis of observational studies. Am J Obstet Gynecol 2017;217:11-26.e3.
The objective of this study was to systematically review existing evidence to summarize the association between pelvic organ prolapse (POP) and obesity as measured by body mass index (BMI), as well as to identify characteristics that can explain the variations in findings across studies. Eligible studies in this meta-analysis were in the English language, had a minimum of 40 subjects of any age, and were required to report effect estimates on the relationship between BMI categories and POP in women. Studies that included postsurgical trial outcomes were not included. The primary outcome for the meta-analysis was the presence of POP in any compartment as a dichotomous variable (yes, no). The authors identified 70 original research articles, of which 22 studies were eligible for the meta-analysis. Eligible articles were unique studies that reported risk ratios between categories of BMI and POP or provided data that allowed for calculation of risk ratios.
The 22 studies in the meta-analysis included more than 95,000 subjects and more than 17,000 cases of prolapse, of which 3,043 cases constituted clinically significant POP. Results demonstrated that compared to subjects in the normal weight BMI category, subjects in the overweight and obese categories had meta-analysis risk ratios of at least 1.54 (95% confidence interval [CI], 1.29-1.83) and at least 1.71 (95% CI, 1.42-2.06), respectively, if objectively measured, clinically significant POP was assessed. Subgroup analyses suggested that the associations between obesity and prolapse were stronger for objectively measured, clinically significant prolapse than for self-reported POP. The association between prolapse and obesity increases as BMI increases.
COMMENTARY
POP is a common condition with prevalence rates varying from 10-50% depending on the age group.1-4 Risk factors for prolapse long have included genetic predisposition, vaginal delivery, parity, aging, and BMI. In a recent systematic review investigating the risk factors for prolapse, Vergeldt et al concluded that obesity was the only truly modifiable risk factor for prolapse.5 In women who desire childbearing, obesity likely remains one of the only truly modifiable risk factors.
The authors of this systematic review and meta-analysis looked more deeply into the relationship between obesity and the risk of prolapse. Briefly, as defined in the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement, a systematic review:
… is a review of a clearly formulated question that uses systematic and explicit methods to identify, select, and critically appraise relevant research, and to collect and analyze data from the studies that are included in the review. Statistical methods (meta-analysis) may or may not be used to analyze and summarize the results of the included studies. Meta-analysis refers to the use of statistical techniques in a systematic review to integrate the results of included studies.6
Systematic reviews and meta-analyses are only as robust as the existing literature allows. The current study was limited by the dearth of prospective studies investigating the relationship between prolapse and BMI and the limited studies that met the authors’ stringent criteria. In addition, the ways in which we have defined and documented prolapse have changed over the years, leading to variability throughout the studies. There are many unanswered questions about the effect of obesity on the development of prolapse, but despite limitations the authors found a positive significant relationship between obesity and prolapse.
BMI is calculated by the formula: weight (kg)/[height (m)]2. Many of us have electronic medical records that automatically calculate BMI. As a reminder, BMI categories are defined as normal/healthy weight (18.5-24.9 kg/m2), overweight (25-29.9 kg/m2), class 1 obesity (30-34.9 kg/m2), class 2 obesity (35-39.9 kg/m2), and class 3 obesity or severe obesity (previously morbid obesity; > 40 kg/m2). More than one-third of U.S. adults suffer from obesity.7 Some estimates predict that 85% of adults will be overweight or obese by 2030 in the United States alone.8
By personal experience, certainly 50% of my patients are overweight or obese. This is an aspect of care we must face head-on and cannot ignore. Studies show that many obese patients receive mistreatment or are subjects of bias, discrimination, or shaming, even within physicians’ offices. When I ask patients and family members about weight, they often relate they have been told to lose weight, but that is about it. Patients truly are eager to receive guidance. However, obesity counseling is one more aspect of care I do not feel trained to address. I recently set out to find resources to help me better discuss this chronic, multifactorial disease with patients.
I discovered that in 2015, Dr. Mark S. DeFrancesco, then ACOG president, developed the Wellness Work Group on Obesity; this work led to the development of an Obesity toolkit.9 This wonderful online resource is available on ACOG.org and includes additional links to other resources such as the Why Weight? provider discussion tool kit developed by the STOP Obesity Alliance.10 Resources such as these speak to the barriers and challenges providers face when addressing obesity, but also provide tools to start these difficult conversations, such as assessing patient readiness, developing communication strategies, setting realistic goals, and more. An obesity algorithm also is available through the Obesity Medicine Association.11
With so many diets on the market, patients frequently ask which diet is best. Just as I have been preparing this commentary, Garnder et al published the results of a randomized, controlled trial comparing low-fat to low-carbohydrate diets in the Journal of the American Medical Association.12 They found that no one dietary strategy was superior, but concluded that dietary modification remains a key to successful weight loss. We don’t have to get caught up in the small details of weight management recommendations. What I have distilled from some of the resources above is that taking a few minutes to open a discussion about weight in a warm, empathic way may allow us to return to the issue with more ease at each subsequent visit. Discussing obesity as a chronic disease can help frame our conversation and make it less threatening. By listening to patients’ experiences, we may be able to better assess their awareness and readiness, and take small steps to help patients identify personal goals. You don’t have to go at it alone. I have been fortunate to partner with the weight management program at our institution to provide patients with dietary and nutrition education, as well as formalized weight loss programs that span diet, medication, and surgery. Your hospital or institution likely has similar resources.
We all know about the morbidity and mortality associated with obesity and the increased risk of hypertension, coronary artery disease, diabetes, cancer, sleep apnea, just to name a few.13 Based on this study, we now can add POP to the many risks associated with obesity. As women’s healthcare providers, we are uniquely poised to help women make strides in grappling with this chronic, debilitating disease throughout many critical life stages.
REFERENCES
- Hendrix SL, Clark A, Nygaard I, et al. Pelvic organ prolapse in the women’s health initiative: Gravity and gravidity. Am J Obstet Gynecol 2002;186:1160-1166.
- Nygaard I, Barber MD, Burgio KL, et al. Prevalence of symptomatic pelvic floor disorders in US women. JAMA 2008;300:1311-1316.
- Samuelsson EC, Victor FT, Tibblin G, Svärdsudd KF. Signs of genital prolapse in a Swedish population of women 20 to 59 years of age and possible related factors. Am J Obstet Gynecol 1999;180(2 Pt 1):299-305.
- Swift S, Woodman P, O’Boyle A, et al. Pelvic Organ Support Study (POSST): The distribution, clinical definition, and epidemiologic condition of pelvic organ support defects. Am J Obstet Gynecol 2005;192:795-806.
- Vergeldt TF, Weemhoff M, IntHout J, Kluivers KB. Risk factors for pelvic organ prolapse and its recurrence: A systematic review. Int Urogynecol J 2015;26:1559-1573.
- PRISMA. Transparent Reporting of Systematic Reviews and Meta-analyses. Available at: http://www.prisma-statement.org/PRISMAStatement/Default.aspx. Accessed Feb. 23, 2018.
- Nguyen DM, El-Serag HB. The epidemiology of obesity. Gastroenterol Clin North Am 2010;39:1-7.
- Hruby A, Hu FB. The epidemiology of obesity: A big picture. Pharmacoeconomics 2015;33:673-689.
- The American College of Obstetricians and Gynecologists. Obesity toolkit. Available at: https://www.acog.org/About-ACOG/ACOG-Departments/Toolkits-for-Health-Care-Providers/Obesity-Toolkit. Accessed Feb. 23, 2018.
- STOP (Strategies to Overcome and Prevent) Obesity Alliance. Why Weight? Available at: http://whyweightguide.org/index.php. Accessed Feb. 23, 2018.
- Obesity Medicine Association. Obesity Algorithm®: Clinical Guidelines for Obesity Treatment. Available at: https://obesitymedicine.org/obesity-algorithm/. Accessed Feb. 23, 2018.
- Gardner CD, Trepanowski JF, Del Gobbo LC, et al. Effect of low-fat vs low-carbohydrate diet on 12-month weight loss in overweight adults and the association with genotype pattern or insulin secretion: The DIETFITS randomized clinical trial. JAMA 2018;319:667-679.
- Centers for Disease Control and Prevention. The Health Effects of Overweight and Obesity. Available at: https://www.cdc.gov/healthyweight/effects/index.html. Accessed Feb. 23, 2018.
Women with a body mass index in the overweight and obese range are more likely to experience pelvic organ prolapse compared to women in the normal range.
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