Understanding Obesity Bias & Its Consequences Susan Reinhardt, RN, BSN Javier Font, EMT-P, EMPT-P

1. Understanding Obesity Bias & Its ConsequencesSusan Reinhardt, RN, BSNJavier Font, EMT-P, EMPT-P

2. 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

3. Bariatric baros – Greek for weight Bariatrics: the practice of health care relating to the treatment of obesity and associated conditions

4. 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)

5. 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

6. BMI-Associated Disease RiskWeight/Height2 (Kg/M2) 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.

7. 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

8. 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

9. Obesity Prevalence by Age & Gender Percent Age in years Source: American Heart Association

10. Obesity by Income Levels 1971-2002 Source: American Heart Association

11. Percentage of Obesity Increase

12. Physiological Impact

13. Physiological Impact of Obesity Idiopathic intracranial hypertension Pulmonary disease abnormal function obstructive sleep apnea hypoventilation syndrome Stroke Cataracts Nonalcoholic fatty liver disease steatosis steatohepatitis cirrhosis Coronary heart disease Diabetes Dyslipidemia Hypertension Severe pancreatitis Gall bladder disease Cancer breast, uterus, cervix colon, esophagus, pancreas kidney, prostate Gynecologic abnormalities abnormal menses infertility polycystic ovarian syndrome Osteoarthritis Phlebitis venous stasis Skin Gout NAASO Obesity Online

14. Diabetes Ann Intern Med 1995; 122:481-6

15. Hypertension Arch Int Med 2000; 160: 898-904

16. Pre-op Medical ConditionsUW Health Data DM=diabetes; HTN=hypertension; HL=hyperlipidemia; OA=osteoarthritis; OSA=obstructive sleep apnea; GERD= Gastroesophageal Reflux Disease Gould, et al, Surgery 2006

17. Obesity and Mortality Risk 2.5 2.0 MortalityRatio 1.5 1.0 VeryLow VeryHigh Low Moderate High 0 20 25 30 35 40 Body Mass Index Gray DS. Med Clin North Am. 1989;73(1):1–13. UW Health Bariatric Surgery Program

18. Prevalence of Obesity in Trauma % J Am College Surg, May 2007, 1056-61

19. 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.

20. What Causes Obesity?

21. Causes of Obesity Psychological Genetic Metabolic Physiologic Medications Behavioral Addiction Environmental Social Cultural Viral Hormonal Economics

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

23. 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

24. 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

25. Obesityis the last bastion of discrimination; the next civil rights hurdle

26. 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 Bias, Stigma & Discrimination

27. What is Weight Bias? • Negative attitude affecting interactions • Stereotypes leading to: • stigma • rejection • prejudice • discrimination • Verbal, physical and relational • Subtle and overt expressions

29. 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

30. 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

32. Why Care?

33. 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

34. 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.

35. Unhealthy behaviors, Poor self-care Obesity Health consequences Cycle of Bias and Obesity Avoidance of health care Increased medical visits Negative feelings Bias in health care Puhl RM, Moss-Racusin CA, Schwartz MB. Obesity Vol. 15 No.1 January 2007

36. How can you make a difference?

37. 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

38. 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 population Puhl & Brownell, 2002

39. 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

40. 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?

41. 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

42. 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

43. 10 Tips for Transporting Obese Patients • 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

44. 10 Tips for Transporting cont’d… • 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

45. 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

46. Thank You!

47. 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