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Care Considerations for the Client Who Is Obese

FULTON, JANET S. PhD, RN

PATIENTS AND CLIENTS: EDITORIAL
Free

From Wright State University, Dayton, Ohio.

Americans are seeing alarming increases in obesity. By all indication, obesity is bad and getting worse. It is true, our society is evolving toward an ever smaller energy expenditure, and our appetites are not keeping pace. The first federal guidelines on the identification, evaluation, and treatment of overweight and obesity in adults were released in 1998 by the National Heart, Lung, and Blood Institute (NHLBI), in cooperation with the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK).

According to estimates by the National Heart, Blood, and Lung Institute, about 97 million adults in the United States are obese, more than one third of all adults and 1 in 5 children (nhlbi.nih.gov/guidelines/obesity). Each year, obesity causes at least 300,000 excess deaths in the U.S. and costs the country more than $100 billion. Obesity increase the risk of morbidity from hypertension; dyslipidemia; type 2 diabetes; coronary heart disease; stroke; gallbladder disease; osteoarthritis; sleep apnea and respiratory problems; and endometrial, breast, prostate, and colon cancers. Obesity is the second leading cause of preventable death in the United States.

Despite its toll taken in death and disability, obesity does not receive the attention it deserves from government, the healthcare profession, or the insurance industry. Research is severely limited by a shortage of funds, inadequate insurance coverage for treatment, and discrimination and mistreatment of people with obesity. According to the American Obesity Association (http://www.obesity.org) the National Institutes of Health annually spends less than 1.0% of its budget on obesity research, or about $1.00 per obese person. Health insurance providers rarely pay for treatment of obesity, despite its serious effects on health. Science has developed clear guidelines for identifying the obese patient. Science has yet to generate adequate insight into the complex interplay between physical, psychologic, and social causes of obesity. As a society, we have even fewer ways to fund a reversal of the growing trend.

Bariatrics is a branch of medicine specializing in care and treatment of obese persons. Bariatrics is a clinical term. Obesity is used in polite conversation. Some sources identify obesity as a condition and morbid obesity as a disease. Obesity means that a person’s body weight is 20% or more greater than the ideal weight for a given height, and that morbid obesity exists if a person is 100 pounds or more above ideal weight for height. The most important cause of obesity is a person’s genetics. I’m sure you’ve heard the old standby, “I’m not too fat, I’m too short, and all my relatives were short.” With the exception of complaining, genetics is the one contributing factor a person can do nothing about. Other important factors are lifestyle, including eating and exercise patterns, and psychologic factors. We all eat at times other than when we are hungry, and often psychologic pressures stimulate increased intake of food. Obesity is not a character flaw.

A bariatric client is an obese client. Fat. Fat is what we too often call these clients in the confines of closed doors, at shift report, during lunch breaks, and in the locker room. We tell amusing anecdotes. We vent our frustrations. Sometimes we are not discrete. Like many physical characteristics, being fat conjures up negative stereotypes and related negative attitudes. Fatism. The “isms” associated with being fat are so prevalent they are almost unrecognized. The National Association to Advance Fat Acceptance (NAAFA) promotes itself as a human rights organization dedicated to improving quality of life for fat people (their term), to eliminating discrimination based on body size, and providing fat people with the tools for self-empowerment through public education, advocacy, and member support (http://www.naafa.org). Surely if there were no fatism, there would be no organization to promote the human rights of obese persons.

Many overweight and obese patients avoid seeking preventative healthcare or symptom evaluation because they either assume that they will get another lecture on weight loss or that accommodations will not meet their special needs. The article by Barr and Cunneen, “Understanding the Bariatric Client and Providing a Safe Hospital Environment,” will remind us of our responsibility to the fundamental needs of obese patients for mobility and safety. The safety checklist provided by the authors is an important reminder that nurses have a responsibility to determine if the environment is safe, and to make the necessary modifications to ensure safety. In hospitals and clinics, CNSs are key to equipment and device evaluation. If you routinely care for obese patients in your healthcare setting, then ongoing evaluation of all equipment is needed to determine its usability and safety. Hospitals and clinics should purchase enough equipment to adequately meet the needs of obese patients, and with the increase in obesity, the demand is growing.

NAAFA publishes guidelines to assist healthcare providers in caring for obese persons. Here are some suggestions from its list; you will find these and others in the article.

  • Acknowledge each patient as an individual, especially fat patients who avoid healthcare because they believe they are only perceived as being fat and that the knee-jerk treatment for any problem is “lose weight.” If they could lose weight, many would have done so by now.
  • Too often, people who are fat are not taken seriously by healthcare providers. Remember that many fat people have had years of negative experiences with healthcare providers, and some have been denied treatment or given inappropriate treatment because they are fat. Treat them with gentleness, tact, and concern.
  • Do not automatically weigh your fat patients, unless there is a compelling reason to do so. If weighing is necessary, ensure that it takes place in a private setting and not in the presence of other patients or staff. The fat patient’s weight should be recorded silently, free of any commentary.
  • Have several sizes of blood pressure cuffs available. Using a small blood pressure cuff on a fat patient can cause false readings.
  • Have longer needles and tourniquets available in order to draw blood from your fat patients.
  • A bathroom with a split front seat on the commode will enable fat patients to more easily hold urine specimen cups in place. A urine specimen collection device with a handle is preferable.
  • Do not automatically assume that the cause of your fat patient’s symptom is his or her weight. Perform the same diagnostic tests on fat patients as would be indicated for average size for a suspected condition.
  • Do not insist that a fat patient lose weight before receiving treatment for conditions that are not weight related.
  • Demonstrate care in prescribing or administering medication. Some fat patients react sensitively to small dosages of some drugs, whereas other drugs require a higher dose, due to the patient’s higher weight.
  • Have several sturdy armless chairs in the waiting room. Chairs with arms often cannot accommodate a fat person. Maintain 6 to 8 inches of space between chairs.
  • Sofas should be firm and high to ensure that your fat patient can easily rise. Exceptionally low and soft sofas can be a nightmare for the fat patient.
  • Examining tables should be wide and bolted to the floor or wall so that the table does not tip forward when your fat patient sits on the end. Provide a sturdy stool for fat patients to assist them in getting on the examining table. Provide super-large examining gowns for fat patients.
© 2001 Lippincott Williams & Wilkins, Inc.