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

2. How many runs involve morbidly obese patients? A. 0/week B. 1-5/week C. 5-10/week D. 10+/week

3. Is the morbidly obese patient a challenge for you? A. Yes B. No

4. Are you comfortable working with people who are morbidly obese? A. Yes B. No

5. Do you feel equipped to handle the morbidly obese patient? A. Yes B. No

6. Obesity is simply a matter of willpower and eating less. A. True B. False

7. Do you make assumptions based on weight of a person’s character, intelligence, professional success, or lifestyle behaviors? A. Yes B. No

8. 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

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

10. 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)

11. 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

12. BMI-Associated Disease Risk Weight/Height 2 (Kg/M 2 ) ClassBMI (kg/m 2 )Disease Risk Underweight<18.5Increased Normal18.5-24.9Normal Overweight25.0-29.9Increased Obesity ClassI30.0-34.9High Severe ObesityII35.0-39.9Very High Morbid ObesityIII>40Extremely High Super ObesityIV>50Extremely High Super Super Obesity V>60 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.

13. 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

14. 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 22 th in nation Trust for America’s Health; 2007

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

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

17. Percentage of Obesity Increase

18. Physiological Impact

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

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

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

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

23. Body Mass Index Gray DS. Med Clin North Am. 1989;73(1):1–13. Obesity and Mortality Risk 2.5 2.0 1.5 1.0 0 2025303540 Mortality Ratio Very Low LowModerateHigh Very High UW Health Bariatric Surgery Program

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

25. 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.

26. What Causes Obesity?

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

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

29. 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

30. 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

31. Obesity is the last bastion of discrimination; the next civil rights hurdle

32. 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

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

35. 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

36. 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

38. Why Care?

39. 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

40. 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.

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

42. How can you make a difference?

43. 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

44. 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

45. 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

46. 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?

47. 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

48. 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

49. 10 Tips for Transporting Obese Patients 1. Always treat obese patient with dignity 2. 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. 3. Never hurry: Even when transporting an emergency patient you must think ahead, anticipate obstacles and proactively resolve problems. 4. Locate obese patients beforehand: Preplan for future runs. 5. Evaluate patient mobility prior to transport Modthan, C. JEMS.com March 2007 taken from “Handle with Care” JEMS Jan. 2002

50. 10 Tips for Transporting cont’d… 6. Scene assessments must be performed at receiving and destination facilities: prior to transport, check width of doors, steps, etc. 7. Vehicle placement: place ambulance so terrain works in your favor. 8. Personnel: make sure you have sufficient personnel to safely move your patient. 9. Have a back-up plan: if cot doesn’t work, have device or material to accommodate. 10. 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

51. 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

52. Obesity is simply a matter of willpower and eating less A. True B. False Answer: False. Obesity is a complicated, multi- factorial, progressive, life-threatening, genetically-related, costly disease

53. Will you continue to make assumptions based on weight of a person’s character, intelligence, professional success, or lifestyle behaviors? A. Yes B. No

54. Do you think you will be more comfortable working with people who are morbidly obese? A. Yes B. No

55. Thank You!

56. 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