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Editorial: Embracing the Problem of Obesity
The obesity rate in the United States has increased fourfold in the last 20 years. This has created many challenges for the healthcare system (Sturm, 2003). Overweight is defined as a body mass index (BMI) between 25 and 29.9, while a BMI of 30 or greater is labeled as obese. These two BMI categories combined account for almost 97 million U.S. adults with another 16% of adolescents aged 6–19 described as overweight (CDC, 2006).
Whether overweight or obese, this designation substantially increases the risk for conditions such as hypertension, type 2 diabetes, coronary heart disease, stroke, gallbladder disease, osteoarthritis, some cancers (endometrial, breast, and colon), sleep apnea, respiratory problems and is commonly associated with an early death (CDC, 2006). Along with the human costs associated with being overweight is the economic impact that accounts for $92.6 billion in medical costs (2002 dollars). This monetary figure does not even include the cost of lost work time or lost productivity (CDC). In addition, altered patient mobility and increased size trigger a host of issues such as staff injuries, inadequately sized equipment, limited staff knowledge concerning appropriate patient care, and environmental and supply issues (e.g., the need for wider doorways and hallways, larger patient gowns).
Within the next 5–10 years, how widespread will be the numbers of bariatric patients? What percentage of our present patient population fits into this category? One hospital in St. Louis, for example, found that almost one third of its 900 patients weighed greater than 350 lbs (Salter, 2006). Unfortunately, this trend does not appear to be unique. How then do we, as rehabilitation nurses, begin to confront the increasing numbers of bariatric patients?
When caring for bariatric patients, a three-pronged approach should be considered (Morissette, 2004; NACNS, 2004). The first component is nurse/practice centered and encompasses several key issues: examining the causes of obesity, identifying personal biases, educating staff regarding specific aspects of bariatric care (e.g., assessment, interventions, and outcomes); and establishing multidisciplinary bariatric teams whenever possible to address quality care issues. For all bariatric patients, specific areas of concern include physical assessment accommodations (e.g., larger blood pressure cuff, auscultation of the heart and breath sounds), nutritional screening, skin and wound care issues, sensitivity to the patient’s emotional state, positioning, mobility, pharmacological considerations (e.g., absorption and administration), discharge planning and follow-up (Hahler, 2002). Safety is also a high priority for both the patient and healthcare providers (HCPs). Data indicate that 89% of back injury claims filed by hospitals are related to patient handling (Gallagher, 1998). Although data are not readily available identifying the percentage of HCPs with back and other injuries attributable to caring for bariatric patients, this professional group frequently complains about the difficulties associated with turning, transferring, and lifting these patients (Hahler). Of particular concern to HCPs is the absence or scarcity of appropriate equipment (e.g., lifts, beds, and transfer devices) and inadequate staffing that contributes to greater safety hazards. A partial solution may be more evidence-based HCP educational programs and care protocols focusing on care essentials for the bariatric patient. Another helpful new informational source is the recently formed (2004) National Association of Bariatric Nurses (www.bariatricnurses.org) with the mission of advancing health, quality of life, and best practice for individuals and families experiencing obesity.
The second element of the bariatric care approach is the patient, the focal point of our actions. Frequently, bariatric patients are slow to seek health care and complain of lack of control and privacy (Gallagher, 1996; Hahler, 2002). For many, impaired mobility, limited transportation options, embarrassment, and reduced physical capabilities are contributing factors to their delay in seeking treatment. After admitted, the hospital equipment, room configuration, and hallways generally do not easily accommodate larger size patients and facilitate their prompt diagnosis, treatment, ambulation, and access to the bathroom that they require. In conjunction with the restrictions associated with their physical environment and limited mobility, approximately 50% of bariatric patients have psychological problems with depression—the most common manifestation (Vaidya, 2006). Thus, assessment and management of these psychological issues are an essential item in the treatment plan. Moreover, as with any patient, determination of individual needs, expectations, preferences, and social support are crucial elements in the care delivery process, but also inclusion of the patients/family in the healthcare plans, long- and short-term goal setting.
The organization delivering care constitutes the final component of the three-pronged care delivery process. Without the appropriate resources, quality care for the bariatric patient is impossible. Essentials include appropriately sized equipment, care protocols and policies based on national evidence-based guidelines (e.g., Safe Patient Handling and Movement Policy), multidisciplinary bariatric care teams, educational programs for patients and staff, patient rooms that easily accommodate bariatric patients as well as organizational and financial support to maximize the patient care situation. It was a challenge 5 years ago to find wheelchairs, beds, lifts, and transporting devices with a 600-lb load capacity, but today several manufacturers carry products and wheelchairs with 1,000-lb limits. With the projected rise in bariatric patients in the next 10 years, healthcare organizations must be responsive to the needs of the bariatric patient population and HCPs. Unfortunately, numerous organizations have been slow to respond, but this trend is changing.
Is your setting in sync, or just beginning to address the challenges associated with the bariatric patient? Given our multidisciplinary approach to care, unique skill set, and experiential background to promote the highest functional level of patients, rehabilitation nurses are well equipped to assume a leadership role using this three-pronged approach to provide quality care.
Centers for Disease Control and Prevention. (2006). Overweight and obesity. Retrieved April, 24, 2006, from www.cdc.gov/nccdphp/dnpa/obesity/faq.htm.
Gallagher, S. (1996). Meeting the needs of the obese patient. American Journal of Nursing, 96(8), Supp1S–12B.
Gallagher, S. M. (1998). Caring for obese patients. Nursing, 28(3), HN1.
Hahler, B. (2002). Morbid obesity: A nursing care challenge. MEDSURG Nursing, 11(2), 85–90.
Morissette, J. (2004). Clinical nurse specialist as leader of a bariatric program. Nursing Leadership Forum, 9(2), 76–79.
National Association of Clinical Nurse Specialists. (2004). Statement of clinical nurse specialist practice and education (2nd ed.). Harrisburg, PA: Author.
Salter, J. (2006). Hospitals make changes to care for the obese. Associated Press, March 31.
Sturm, R. (2003). Increases in clinical severe obesity in the United States. Archives of Internal Medicine, 163, 2146–2148.
Vaidya, V. (2006). Psychological aspects of obesity. Advances in Psychosomatic Medicine, 27, 73–85.