Transcript Understanding Obesity Bias & Its Consequences Susan Reinhardt,

Understanding Obesity Bias &
Its Consequences
Susan Reinhardt, RN, BSN
Javier Font, EMT-P, EMPT-P
Learning Objectives
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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 weight
Bariatrics: the practice of health care
relating to the treatment of obesity and
associated conditions
Definitions
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Overweight ~ an excess of body weight
compared to standards. This could come
from muscle, bone, fat and/or water.
(BMI 25-29.9)
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Obesity ~ refers specifically to the abnormal
proportion of body fat. (BMI 30-40)
Morbid Obesity
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>100 pounds overweight or a Body Mass
Index (BMI) of 40
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Morbid obesity is a complicated, multifactorial, 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)
Underweight
Normal
Overweight
Obesity Class
Severe Obesity
Morbid Obesity
Super Obesity
Super Super
Obesity
Disease Risk
I
II
<18.5
18.5-24.9
25.0-29.9
30.0-34.9
35.0-39.9
Increased
Normal
Increased
High
Very High
III
IV
>40
>50
V
>60
Extremely High
Extremely High
Extremely 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.
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American Adults
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66.2% are overweight or obese
32.9% are obese
5% are morbidly obese
American Children
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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
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Adults
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Children
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61.8% are overweight or obese
24.8% are obese
46.8% are physically inactive
22.7% smoke cigarettes
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
Obesity Prevalence by Age & Gender
40
35
30
Percent
25
Men
Women
20
15
10
5
0
Total
20-39
40-59
Age in years
60 and over
Source: American Heart Association
Obesity by Income Levels
1971-2002
35
1971 - 1974
2001 - 2002
30
Percent Obese
25
20
15
10
5
0
<$25,000
$25,000-$40,000
Income
$40,000-$60,000
>$60,000
Source: American Heart Association
Percentage of Obesity Increase
Physiological Impact
Physiological Impact of Obesity
Pulmonary disease
abnormal function
obstructive sleep apnea
hypoventilation syndrome
Nonalcoholic fatty liver
disease
Idiopathic intracranial
hypertension
Stroke
Cataracts
steatosis
steatohepatitis
cirrhosis
Coronary heart disease
Diabetes
Dyslipidemia
Hypertension
Gall bladder disease
Severe pancreatitis
Gynecologic abnormalities
Cancer
abnormal menses
infertility
polycystic ovarian syndrome
breast, uterus, cervix
colon, esophagus, pancreas
kidney, prostate
Osteoarthritis
Skin
Gout
Phlebitis
venous stasis
NAASO Obesity Online
Diabetes
70
60
50
Age-adjusted 40
Relative Risk 30
20
10
0
<22 23
24
25
27
29
31
33
35 >35
BMI
Ann Intern Med 1995; 122:481-6
% Polulation
Hypertension
40
35
30
25
20
15
10
Men
Women
5
0
<25
25-26
27-29
>30
BMI
Arch Int Med 2000; 160: 898-904
Pre-op Medical Conditions
UW Health Data
70
64
60
54
54
50
46
41
40
%
30
33
39
BMI > 60
BMI < 60
32
29
23
48
21
20
10
0
DM
HTN
HL
DM=diabetes; HTN=hypertension; HL=hyperlipidemia;
OA=osteoarthritis; OSA=obstructive sleep apnea; GERD=
Gastroesophageal Reflux Disease
OA
OSA
GERD
Gould, et al, Surgery 2006
Obesity and Mortality Risk
2.5
2.0
Mortality
Ratio
1.5
1.0
Very
Low
Low
Moderate
Very
High
High
0
20
25
30
35
40
Body Mass Index
UW Health Bariatric Surgery Program
Gray DS. Med Clin North Am. 1989;73(1):1–13.
Prevalence of Obesity in
Trauma
40
36
35
%
34
30
24
25
20
BMI
15
10
6
5
0
18.5-24.9
25-29.9
30-39.9
>40
J Am College Surg, May 2007, 1056-61
Assessment Challenges
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Respiratory
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Cardiology
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Compromised mechanics of respiration
 Difficult auscultation, airway management, positioning
Cardiac structure and function alterations
 Difficult auscultation, access
Trauma Patterns
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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
Psychological
Genetic
Metabolic
Physiologic
Addiction
Medications
Behavioral
Environmental
Social
Cultural
Economics
Viral
Hormonal
Influencing Factors
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Environmental
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design foster driving
lack of public transportation; sidewalks
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Fast food
Higher density calories
Bigger portions – Super-size culture
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Convenience
Less in-home cooking
Fast, easier to prepare
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Family, Home, School, Work
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Cultural
Work more, home less
Parents/family/co-workers habits
Desk jobs
Unhealthy options
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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
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Food Choices
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Economic Constraints
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Changes in Food
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Electronic culture
Communities not designed for physical activity
Family history
Metabolism
Hormones - ghrelin
Childbearing
Aging factors
Psychology
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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
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~48,000,000 Americans on any given day on a
diet
1,200+ different diet books
Americans spend $50 billion annually on diet
products
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
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
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?
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Negative attitude affecting interactions
Stereotypes leading to:
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stigma
rejection
prejudice
discrimination
Verbal, physical and relational
Subtle and overt expressions
Physician Bias
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Physicians feel that people with obesity
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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
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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
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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
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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
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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-care
Avoidance of
health care
Obesity
Cycle of Bias and
Obesity
Health
consequences
Increased medical
visits
Negative feelings
Bias in health care
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
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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
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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
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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 population
Puhl & Brownell, 2002
Addressing the Patient
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Avoid making remarks
about size
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Be mindful when asking for
equipment; don’t ask for
the “BIG” anything in front
of the patient
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Ask the patient what works
for them
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Pre-plan
Source: Obesityhelp.com message board responses 2/04
Challenges
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Delayed access to preventative and/or routine
medical care means a sicker or severely
compromised individual
Impact on transport time
Appropriate equipment?
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Transport/transfer
Accurate readings or starting line
Able to elevate head?
Enough lifting-power to make transfer/transport?
Impact on EMS
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Personnel
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Equipment
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Stretcher
Air-powered lift system
Stair chair
Ambulances
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Additional crews to assist
Bariatric
Electric winches w/automatic braking system
Finances
Possible Solutions
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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.
2.
3.
4.
5.
Always treat obese patient with dignity
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.
Never hurry: Even when transporting an
emergency patient you must think ahead,
anticipate obstacles and proactively resolve
problems.
Locate obese patients beforehand: Preplan for
future runs.
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.
7.
8.
9.
10.
Scene assessments must be performed at
receiving and destination facilities: prior to
transport, check width of doors, steps, etc.
Vehicle placement: place ambulance so terrain
works in your favor.
Personnel: make sure you have sufficient
personnel to safely move your patient.
Have a back-up plan: if cot doesn’t work, have
device or material to accommodate.
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….
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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
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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