Understanding Obesity Bias & Its Consequences

Susan Reinhardt, RN, BSNJavier Font, EMT-P, EMPT-P

Learning Objectives

Understand the physiological and psychosocial impact of obesity on your patients

Learn the biases that exist toward the morbidly obese person by healthcare and effective strategies to improve patient-caregiver communications

Discuss the importance of pre-planning in management of a complex bariatric patient

Bariatric

baros – Greek for weightbaros – Greek for weight

Bariatrics: the practice of health care relating to the treatment of obesity and

associated conditions

Definitions

Overweight ~ an excess of body weight compared to standards. This could come from muscle, bone, fat and/or water. (BMI 25-29.9)

Obesity ~ refers specifically to the abnormal

proportion of body fat. (BMI 30-40)

Morbid Obesity

>100 pounds overweight or a Body Mass Index (BMI) of 40

Morbid obesity is a complicated, multi-factorial, progressive, life-threatening, genetically-related, costly disease of excess fat storage with multiple obesity related health conditions

American Society for Bariatric Surgery

BMI-Associated Disease Risk Weight/Height2 (Kg/M2)

Class BMI (kg/m2) Disease Risk

Underweight <18.5 IncreasedNormal 18.5-24.9 NormalOverweight 25.0-29.9 IncreasedObesity Class I 30.0-34.9 High

Severe Obesity II 35.0-39.9 Very High

Morbid Obesity III >40 Extremely High

Super Obesity IV >50 Extremely HighSuper Super Obesity

V >60Extremely High

Clinical Guidelines on the Identification, Evaluation, and Treatment of Overweight and Obesity in Adults—The Evidence Report. Obes Res 1998;6(suppl 2). Extreme often referred to as Clinically Severe Obesity or Morbid Obesity.

Obesity in U.S. American Adults

66.2% are overweight or obese 32.9% are obese 5% are morbidly obese

American Children 17% between 2-19 yrs (or over 12.5 million)

children/adolescents are overweight

National Health and Nutrition Examination Survey (NHANES), which is conducted by CDC’s National Center for Health Statistics. 2006

Obesity in Wisconsin Adults

61.8% are overweight or obese 24.8% are obese 46.8% are physically inactive 22.7% smoke cigarettes

Children 23.6% of high-school students overweight or at risk 29% low-income children between 2-5 yrs are overweight

or at risk

Ranked 22th in nation

Trust for America’s Health; 2007

0

5

10

15

20

25

30

35

40

Total 20-39 40-59 60 and over

Men

Women

Obesity Prevalence by Age & Gender

Age in years

Per

cent

Source: American Heart Association

0

5

10

15

20

25

30

35

<$25,000 $25,000-$40,000 $40,000-$60,000 >$60,000

Pe

rce

nt

Ob

es

e

1971 - 1974

2001 - 2002

Income

Obesity by Income Levels 1971-2002

Source: American Heart Association

Percentage of Obesity Increase

Physiological Impact

Pulmonary diseasePulmonary diseaseabnormal functionabnormal functionobstructive sleep apneaobstructive sleep apneahypoventilation syndromehypoventilation syndrome

Nonalcoholic fatty liver Nonalcoholic fatty liver diseasediseasesteatosissteatosissteatohepatitissteatohepatitiscirrhosiscirrhosis

Coronary heart diseaseCoronary heart disease

DiabetesDiabetes

DyslipidemiaDyslipidemia

HypertensionHypertension

Gynecologic abnormalitiesGynecologic abnormalitiesabnormal mensesabnormal mensesinfertilityinfertilitypolycystic ovarian syndromepolycystic ovarian syndrome

OsteoarthritisOsteoarthritis

SkinSkin

Gall bladder diseaseGall bladder disease

CancerCancerbreast, uterus, cervixbreast, uterus, cervixcolon, esophagus, pancreascolon, esophagus, pancreaskidney, prostatekidney, prostate

PhlebitisPhlebitisvenous stasisvenous stasis

GoutGout

Physiological Impact of ObesityIdiopathic intracranial Idiopathic intracranial hypertensionhypertension

StrokeStroke

CataractsCataracts

Severe pancreatitisSevere pancreatitis

NAASO Obesity Online

Diabetes

0

10

20

30

40

50

60

70

Age-adjusted Relative Risk

<22 23 24 25 27 29 31 33 35 >35

BMIAnn Intern Med 1995; 122:481-6

Hypertension

0

5

10

15

20

25

30

35

40

% P

olu

lati

on

<25 25-26 27-29 >30

BMI

MenWomen

Arch Int Med 2000; 160: 898-904

Pre-op Medical Conditions UW Health Data

29

64

21

54

39

46

23

54

33

41

32

48

0

10

20

30

40

50

60

70

DM HTN HL OA OSA GERD

%BMI > 60

BMI < 60

Gould, et al, Surgery 2006

DM=diabetes; HTN=hypertension; HL=hyperlipidemia; OA=osteoarthritis; OSA=obstructive sleep apnea; GERD= Gastroesophageal Reflux Disease

Body Mass Index

Gray DS. Med Clin North Am. 1989;73(1):1–13.

Obesity and Mortality Risk

2.5

2.0

1.5

1.0

020 25 30 35 40

Mortality

Ratio

VeryLow

Low Moderate HighHighVeryVeryHighHigh

UW Health Bariatric Surgery Program

Prevalence of Obesity in Trauma

3634

24

6

0

5

10

15

20

25

30

35

40

18.5-24.9 25-29.9 30-39.9 >40

BMI

%

J Am College Surg, May 2007, 1056-61

Assessment Challenges Respiratory

Compromised mechanics of respiration Difficult auscultation, airway management, positioning

Cardiology Cardiac structure and function alterations

Difficult auscultation, access Trauma Patterns

Increased lower extremity injuries Increased chest/diaphragm injuries Fewer head injuries

Brown et al, Impact of obesity on outcomes of 1153 critically injured blunt trauma patients. J Trauma, 2005:59;1058-51.

What Causes Obesity?

Causes of Obesity

Metabolic

Genetic

Physiologic Medications

Behavioral

CulturalSocial

Psychological

AddictionEnvironmental

Economics HormonalViral

Influencing Factors Environmental

Electronic culture Communities not designed for physical activity

design foster driving lack of public transportation; sidewalks

Changes in Food Fast food Higher density calories Bigger portions – Super-size culture

Food Choices Convenience Less in-home cooking Fast, easier to prepare

Family, Home, School, Work Cultural Work more, home less Parents/family/co-workers habits Desk jobs Unhealthy options

Economic Constraints Insurance coverage for obesity-prevention is

limited or not available Lack of health insurance Lower-income neighborhoods have less groceries

(less fruits/veggies) and more fast food chains Value sizing less nutritious food and higher costs

of nutritious Genetics, Physiology and Life-Stages

Family history Metabolism Hormones - ghrelin Childbearing Aging factors

Psychology Greater advertising/marketing of less nutritious

foods Body image – media, societal Diet mentality Eating to combat stress, to sooth Compulsive eating Addictive personalities Childhood trauma Post-traumatic Stress Disorder

F as in Fat: How Obesity Policies are Failing; Trust for America’s Health. Issue Report 2006

Commercial Weight Loss Statistics

~48,000,000 Americans on any given day on a diet

1,200+ different diet books Americans spend $50 billion annually on diet

products

85% of Americans believe that obesity is an epidemic

in this country.Greenberg Quinlan Rosner Research, Inc Survey, July 2007

F as in Fat: 2007

A nationwide survey exposed that

physicians consider obesity to be

the single largest public health crisis in the U.S.

2007 Obesity Report by Epocrates, Inc

Obesity is the last bastion of discrimination; the next civil rights hurdle

Bias, Stigma & Discrimination

Social Lazy Less Intelligent Bad person Responsible for their own

condition Imperfect body reflects

imperfect person Get what they deserve and

deserve what they get (discrimination is acceptable)

Physical/Environmental Limited healthcare

resources (Ambulances, carts, exam tables, radiology equipment, BP cuffs, etc)

Seats at theaters, conference centers, places of employment, on airplanes and buses

Toilet-shower cubicles Clothing choice and prices

What is Weight Bias?

Negative attitude affecting interactions Stereotypes leading to:

stigma rejection prejudice discrimination

Verbal, physical and relational Subtle and overt expressions

Physician Bias Physicians feel that people with obesity

Are noncompliant Are hostile Are dishonest Weak-willed Lack self control Unsuccessful Unintelligent Lazy Have poor hygiene

69% of overweight and obese women experienced bias against them by doctors and 52% the bias occurred more than once

Puhl R, Brownell KD, Obes Res 2001 Dec;9(12):788-805

Nurses Bias Noncompliance most likely reason for obese patient's

inability to lose weight 63% agreed obesity can be prevented by self-control 24% reported they are repulsed by the obese 48% felt uncomfortable caring for the obese 31% prefer not to care for the obese 24% agree that obese people are unsuccessful 24% are repulsed 22% think they are lazy 12% prefer not to touch an obese person

Puhl R, Brownell KD, Obes Res 2001 Dec;9(12):788-805

Why Care?

Consequences of Bias & Stigma

Social rejection, poor quality relationships, worse academic outcomes and lower socio-economic status

Reluctant to seek medical care Put off important preventive health services and

exams More frequent cancellation or delay in appointments Less time spent with the physician

Less intervention Less discussion More often assign negative symptoms

Puhl R, Brownell KD, Obes Res 2001 Dec;9(12):788-805

Consequences of Bias & Stigma Internalize stigma, accept negative attitudes, leading

to an increase in low self-esteem In response to stigmatizing encounters, may

interfere with weight loss attempts and cause person to eat more

Those that internalize stereotypes may be more likely to binge eat and less likely to diet

Less confidence in their ability to successfully lose weight due to self-blame

Puhl RM, Moss-Racusin CA, Schwartz MB. Obesity Vol. 15 No.1 January 2007.

Unhealthy behaviors, Poor

self-careObesity

Health consequences

Increased medical visits

Bias in health careNegative feelings

Avoidance of health care

Cycle of Bias and Obesity

Puhl RM, Moss-Racusin CA, Schwartz MB. Obesity Vol. 15 No.1 January 2007

How can you make a difference?

Identify One’s Own Bias Do I make assumptions based only on weight

regarding a person’s character, intelligence, professional success, health status, or lifestyle behaviors?

Am I comfortable working with people of all shapes and sizes?

Do I give appropriate feedback to encourage healthful behavior change?

Am I sensitive to the needs and concerns of obese individuals?

Do I treat the individual or the condition?

KD Brunell and RM Puhl. AMA Virtual Mentor. 2006; 8:298-302

Ways to Increase Sensitivity Recognize the complex etiology of obesity and its

multiple contributors Recognize that many obese patients have tried to

lose weight repeatedly Be sensitive to the person’s feelings

Use empathy and compassion Provide support and encouragement Respectful and motivational communications

Watch body language Have adequate equipment and supplies available

to care for bariatric populationPuhl & Brownell, 2002

Addressing the Patient

Avoid making remarks about size

Be mindful when asking for equipment; don’t ask for the “BIG” anything in front of the patient

Ask the patient what works for them

Pre-plan

Source: Obesityhelp.com message board responses 2/04

Challenges

Delayed access to preventative and/or routine medical care means a sicker or severely compromised individual

Impact on transport time Appropriate equipment?

Transport/transfer Accurate readings or starting line Able to elevate head?

Enough lifting-power to make transfer/transport?

Impact on EMS

Personnel Additional crews to assist

Equipment Stretcher Air-powered lift system Stair chair

Ambulances Bariatric Electric winches w/automatic braking system

Finances

Possible Solutions Address concerns on the handling of patients at

various weights Identify patient-movement strategies in both

emergent and non-emergent situations Set limits on the minimum number of people

required to lift patient over specified weight Require staff to request lift assistance Consider creating a special response unit that could

be shared resource Administrators must assess their systems and

circumstances plus review finances and operations, crew configuration, share resources

10 Tips for Transporting Obese Patients

1. Always treat obese patient with dignity2. Establish a system to safely handle bariatric

transports: write protocols so crew knows what to do. Practice for these runs. Assign someone to specialize in bariatric transfers.

3. Never hurry: Even when transporting an emergency patient you must think ahead, anticipate obstacles and proactively resolve problems.

4. Locate obese patients beforehand: Preplan for future runs.

5. Evaluate patient mobility prior to transport

Modthan, C. JEMS.com March 2007 taken from “Handle with Care” JEMS Jan. 2002

10 Tips for Transporting cont’d…

6. Scene assessments must be performed at receiving and destination facilities: prior to transport, check width of doors, steps, etc.

7. Vehicle placement: place ambulance so terrain works in your favor.

8. Personnel: make sure you have sufficient personnel to safely move your patient.

9. Have a back-up plan: if cot doesn’t work, have device or material to accommodate.

10. Moving from bed to cot: never use a cot that’s not designed to hold your patient’s weight. Use slide board or air mattress.

Modthan, C. JEMS.com March 2007 taken from “Handle with Care” JEMS Jan. 2002

Remember….

Morbid obesity has a complex etiology and multiple contributors, including genetics, biology, sociocultural influences, the environment, and individual behavior

Morbid obesity is a disease with significant co-morbid conditions

Planning is essential to safety Treat patient with respect and dignity

Thank You!

References Barishansky, RM, O’Connor, KE. (2007) Bariatric Patients Pose Weighty Challenges. JEMS/EMS Insider

Vol.34;No.8. Buchwald H. (2005) Consensus Conference Statement: Bariatric surgery for morbid obesity: health

implications for patients, health professionals, and third-party payers. J Am Coll Surg;200:593– 604 Clinical Guidelines on the Identification, Evaluation, and Treatment of Overweight and Obesity in Adults—

The Evidence Report. Obes Res 1998;6(suppl 2). Extreme often referred to as Clinically Severe Obesity or Morbid Obesity.

Drake, D., Dutton, K., et al. (2005) Challenges that nurses face in caring for morbidly obese patients in the acute care setting. Surgery for Obesity and Related Diseases. 1. 462-466

F as in Fat: How Obesity Policies are Failing; Trust for America’s Health. Issue Report 2006 and 2007 Gallagher, S. (2005) The Challenges of Caring for the Obese Patient. Matrix Medical Communications.

Edgemont, PA. Modthan, C. JEMS.com March 2007 taken from “Handle with Care” JEMS Jan. 2002 National Health and Nutrition Examination Survey (NHANES), which is conducted by CDC’s National

Center for Health Statistics. 2006 www.obesityhelp.com Puhl R, Brownell KD, (2001) Obes Res. Dec;9(12):788-805 Puhl, R.M, (2008) Weight bias prevention tool kit for healthcare providers. Yale Rudd Center.

http://www.yaleruddcenter.org/what/bias/toolkit/index.html Puhl, RM., Brownell, KD, (2006) Confronting and Coping with Weight Stigma:An Investigation of

Overweight and Obese Adults. OBESITY Vol. 14 No. 10 October 1802 -1815. Puhl, RM., Moss-Racusin, CA, et al. (2007). Weight stigmatization and bias reduction: perspectives of

overweight and obese adults. Health Education Research. Vol. 23, no. 2, 347-358. Puhl, RM., Moss-Racusin, CA, Schwartz, MB., (2007) Internalization of Weight Bias: Implications for

Binge Eating and Emotional Well-being. OBESITY Vol. 15 No. 1 January. 19-23. Trust for America’s Health; 2007