1. Considerations in the care of the Bariatric Patient
Presented by Amanda Smith, PT,DPT
March 15, 2016

2. Terminology
Overweight – weight over and above what is required or allowed, excessive or burdensome weight
Obesity – a condition characterized by the excessive accumulation and storage of fat in the body
Bariatric – specializing in the treatment of obesity
Lets discuss the terminology: According to the merriam webster online dictionary

3. Obesity
BMI = weight (kg)/ height (m) ^2 BMI = ( Weight in Pounds / ( Height in inches x Height in inches ) ) x 703
BMI
Below 18.5
Underweight
Normal or Healthy Weight
Overweight
Obese (Class 1)
35 – 39.9
Obese (Class2)
40 and above
Morbidly Obese
There are many BMI calculators available online or apps available on your phone. Some charts also show classes of obesity with BMI as obesity class 1, obesity class 2, BMI > 40 as morbidly obese. So if you are working with a 40 year old male who is 5 foot 9 inches and 350 pounds their BMI would be 51.7 over 50 and requiring bariatric equipment.

4. Waist Measurement Waist circumference
Increased risk for heart disease and Type II Diabetes
> 35 inches in women
> 40 inches for men
In addition to BMI waist circumference should be considered. Larger waist circumference is associated with increased risk for heart disease and Type II diabetes. > 35 inches in women and > 40 inches for men

5. Obesity Causes Behavioral Genetics Environment Disease and drugs
These are in no particular order
Diseases Cushings poly cystic ovary syndrome
Drugs steriods and antidpressents

6. Health Consequences Mortality Sleep apnea HTN CA High LDL, low HDL
Breast, colon, kidney, gallbladder, liver, endometrial
Type 2 Diabetes
Coronary Heart Disease
Mental disorders
Anxiety, depression
Stroke
Back pain
Gallbladder Disease
Low quality of life OA

7. Bariatrics
branch of medicine that deals with the causes, prevention, and treatment of obesity
The definitiion according to wikipedia The term bariatric is greek in origin and means weight treatment
Bushard, 2002

8. Bariatric Population
“limitation in health due to physical size, health, mobility, and environmental access”
Most clinicians define the bariatric patient as one who needs bariatric equipment (exceeding limit for standard equipment)> 300 pounds or BMI > 50
Bariatric is someone who is morbidly obese
300 pounds or BMI > 50
Lets say the average american man is 5’9 and weighs 350 BMI = 51

9. Prevalence of Obesity 2014
This map is from the cdc website. In 2014, the midwest has the highest prevalance of obesity. no state has < 20 %, 19 states including Pennsylvania are between 30 and 35%, 3 states(arkansas, mississippi, west virginia) are > 35% ,
Just to give you an idea of the growth of obesity in states had obesity less then 10%, In 2000 no state had less then 10%, in 2010 no state had less then 20% In this map we can see very few dates are still in the 20 to 25% range.
I should also mention the CDC has data on the prevalnce of obesity in non hispanic white adults, non hispanic black adults, and hispanic adults.

10. Cost Implications
The estimated annual medical cost of obesity in the U.S. was $147 billion in 2008 U.S. dollars
The medical costs for people who are obese were $1,429 higher than those of normal weight
Over 1/3 of the population is considered obese therefore there are large cost implications

11. Patients with obesity

12. Patient Considerations
Psychosocial
Cultural importance of the body
Increased awareness and consciousness of the body
Diet industry
Media
Cultural importance of lean body
Barriers
Physical
Emotional
Think of the barriers a bariatric patient may face on regular basis transportation, parking, chairs ( can they fit and sit comfortably), doorways (are the able to get through)
Also have to consider obese visitors

13. Patient Considerations
Weight bias
Stereotypes
Discrimination
Rejection
Prejudice
Fear/avoidance of healthcare

14. Weight bias WHERE? WHY? Home Work School Health and fitness settings
Because the body is malleable
Social conscious
Belief of other people’s stereotypical beliefs
Attributions
Internal and controllable (lazy, lack motivation, etc)
Home – family members are #1source health care providers are #2 in discrimination Puhl & Brownell, 2001; Puhl & Heuer, 2009)
, job - interviews

15. How PTs talk about obesity
Patients are not affected by stigma
Patients are difficult to treat
Weight as having a simple cause
Weight loss as the most important component in physical therapy
Their responsibility to have the weight discussion
Setchell et al 2016

16. Patient Response to Weight Bias
Poor self esteem/depression
Avoidance of medical care
Over eating/ binge eating disorders
Physical inactivity
Puhl & Brownell, 2001; Puhl & Heuer, 2009

17. Considerations Physical space Word choice: Patient first language
Obese and overweight have a negative association
Least preferred: fatness, excess fat, obesity and large size
More preferred: weight, heaviness, BMI, excess weight, unhealthy body weight, weight problem, and unhealthy BMI
As physical therapists we should employ strategies to avoid weight bias. We need consider the physical space. Is the patient comfortbale/ Patient first language means saying the patient with obesity not the obese patient
(Wadden & Didie, 2003)

18. Considerations Previous healthcare experiences
Establishing a patient clinician relationship
PLOF
Considering all causes of patient impairments not just size or weight
Focus on patient centered goals, do not make the focus on weight loss
Any physical activity improves health
Any weight loss improves health
As physical therapists we should employ strategies to avoid weight bias. We should consider that the patient may have had negative experiences in the past when dealing with healthcare providers. Remember healthcare providers are considered the 2nd llargest source of bias to obese patients. Establish the PLOF if the patient wishes to get up how did they get up before? We should focus on the patient clinician relationship and try to establish a rapport. Consider all of the causes of the patients impairments and not just size or weight. Focus on patient centered goals and be careful not to push weight loss onto the patient if that is not their goal.

19. Mobilization Considerations
Objective Measures
Weight, Equipment available, set up
Comorbidities
# needed to assist
Skin integrity
Dionne’s Egress Test
With obese patients generally move slow and allow for rest they will sometimes report that they feel like they are still moving if part of them for example the pannus s still transitioning to the nest position so be very mindful of positioning and check in with patient during movement

20. Medical Conditions Affecting Safe Patient Handling
Pain
Orthopedic conditions
Falls
Poor skin integrity
Postural hypotension
Weakness, paresis
Respiratory
Amputations
Stomas
Tubes/drains

21. Considerations Weight bearing Strength Cooperation and Comprehension
BMI
On page 10 of the safe handling article there is a sheet to list all of these

22. Patient Body Types Bariatric body types according to Michael Dionne,PT
Pear Abduction
Pear Adduction
Gluteal Shelf
Apple Pannus
Apple Ascites
Apple pannus – “inferior abdominal drift”, the lower the abdomen goes to the floor the higher the grade, you do not want to roll this body type because the pannus can continue to move and may cause a fall
Apple ascites – large abdomen – theses are the patients that can’t tolerate lying flat, log rolling may be easier then trying to come supine to sit
Pear abduction – can go supine to long sitting, difficult to roll b/c legs can not touch, knee valgus
Pear adduction – can log roll or supine to sit
Gluteal shelf – large gluteal mass, may need support under low back in supine

23. Apple Pannus Inferior abdominal drift Do not roll
Abduct and externally rotate LE’s to stand
Extend knees first and then trunk
Apple pannus – “inferior abdominal drift”, the lower the abdomen goes to the floor the higher the grade, you do not want to roll this body type because the pannus can continue to move and may cause a fall

24. Apple Ascites Large abdomen Can’t tolerate lying flat
Log rolling may be easier than supine to sit
Consider arm rest to help push COG forward, consider seat height and depth

25. Pear Abduction More mass in the inner thighs Supine to long sitting
Difficult to roll b/c legs can not touch
Demonstrate knee valgus
To stand knee extension first then trunk extension
Leg rest position
Curved armrest

26. Pear Adduction More mass outer thighs Log roll or supine to sit
Leg rest position
Curved armrests

27. Gluteal Shelf Large gluteal mass
May need support under low back in supine
Decreased tolerance in supine
Curved armrest
May need a cutout in the seat back

28. Equipment Considerations
Weight capacity
Width
Trapeze over the bed
Lifts
Sling rating
Visitors
Want to have any available tool to have the patient assist you in mobility want them as independent as possible

29. Equipment Safety Checklist
Bed WC
Chair
Commode/bathroom AD
Want to have proper rated equipment
Want to be prepared and have these items in place prior to getting the patient up

30. Bariatric Equipment
Usually for > 300 pounds
EC – extended capacity

31. Bed
The one pictured si 500 pound, there are beds available for 850 pound, 1000 pound
Can have trapeze

32. Bed pan
1,200 pound capacity , 650 lbs

33. Walker
500 pounds
Have walkers for pannus

34. Crutches

35. Canes
500 lbs

36. Commode
One pictured is 1000, also available 650 pounds

37. Wheelchair
700 lb capacity

38. Goals Rolling Sitting Transfers Walking Bed into chair position
We already talked about Dionne’s recommendations for bed mobility for the different body classifications
For sitting on EOB there are several considerations, in general I am always aware or guarding at the knees in sitting

39. Rolling
Patients ability to assist
Body type

40. Sitting This is the alogrithim from the safe handling article
If you are going to egress form the side of the bed remember the body types

41. SPT

42. Dionne’s Egress Test
1) Raise buttocks off of bed then perform 2 x sit to stand
2) March in place 3 reps
3) Advance each limb forward and backward
Pass/fail grading
Add video

43. Physical Activity Guidelines
Avoid inactivity
Aerobic Activity
10 min bouts
150 minutes moderate intensity per week
75 minutes of vigorous activity per week
Combo
Double the time to increase benefits
Strength Training
Moderate to high intensity 2x/week
US department of Health and Human Services Office of Disease Prevention and Health Promotion
Physical Activity Guidelines for adults

44. Safety Body mechanics of all staff Adequate number of staff to assist
The right equipment/ set up
If an patient that is obese falls you can protect the head clear objects out of the way

45. References
Setchell J, Watson BM, Gard M, Jones L. Physical Therapists’ Ways of Talking About Overweight and Obesity: Clinical Implications. Physical Therapy, 2016; 96
NHLBI Managing Overweight and Obesity in Adults: Systematic Evidence Review from the Obesity Expert Panel. 
Lissner, L. Psychosocial aspects of obesity: individual and Societal Perspectives. Scandinavian Journal of Nutrition, 1997; (41) 75-79
Puhl RM, Heuer CA. The Stigma of Obesity: A Review and Update. Obesity, 2009; (17)
Puhl RM, Brownell KD. Confronting and coping with weight stigma: an investigation of overweight and obese adults. Obesity, 2006; 14(10) 1802-­‐15
Rucks KR. Does one size really fit all? Part1- Defining Obesity and Bariatric Physical Therapy. Available:
Vartanian LR, Novak SA. Internalized societal attitudes moderate the impact of weight stigma on avoidance of exercise. Obesity. 2011; 19(4):
Dionne, M (2006) Among Giants: Courageous Stories of Those Who Are Obese and Those Who Care for Them.
Kelly. SA (2008) Systematic review of multicomponent interventions with overweight middle adolescent: implications for clinical practice. Worldviews Evidence Based Nursing. 5(3):
Gatineau M, Dent M. Obesity and Mental Health. Oxford: National Obesity Observatory, 2011

46. Resources Definitions: http://www.merriam-webster.com/dictionary
Obesity rates by state:
Obesity cost:
Move Forward: Physical Therapist’s Guide to Obesity
Physical Activity Guidelines for Adults
Weight Bias:

47. Discussion