The percentage of adults in the United States considered to be overweight or obese has increased to more than 60 percent.1 Clinical guidelines from the National Institutes of Health2 define overweight as a body mass index (BMI) of 25 to 29.9 kg per m2, while obesity is defined as a BMI of 30 kg per m2 or more (Table 1).2 Of special concern is the dramatic increase from approximately 15 to 27 percent in the category of obesity during the past two decades.1 BMI correlates significantly with total body fat content.2 It is calculated by dividing weight (in kg) by height (in m2) or, alternatively, by dividing weight (in lb) by height (in inches2) and multiplying by 703. Figure 12 provides a chart to calculate BMI, and a BMI calculator is available online at:http://www.nhlbisupport.com/bmi/.
|18.5 to 24.9
|25 to 29.9
|30 to 34.9
|35 to 39.9
Obesity disproportionately affects racial and ethnic minority populations, especially women. For example, 10.3 percent of African American women are extremely obese (defined as a BMI of 40 kg per m2 or more), compared with 6.2 percent of non-Hispanic white women.3 Based on the high prevalence rates of obesity in all population groups, virtually every physician can expect to provide medical care for patients who are obese.
Overweight and obesity confer increased health risks to numerous organ systems, and the risk of developing obesity-related disease is affected by the degree of overweight and the distribution of body fat.4 It is also possible that at least some of the health problems experienced by persons who are obese are worsened by lack of access to care because of their obesity.
Results from several studies5–7 suggest that patients who are obese are less likely to receive certain preventive care services, such as pelvic examinations, Papanicolaou (Pap) smears, and physician breast examinations, than those who are not obese. It is unclear whether this is a result of patient or physician factors. For example, physicians may be less likely to perform pelvic examinations on patients who are obese, because of the difficulty in performing an adequate examination.7 In addition, the greater likelihood of concomitant health problems in obese patients, such as diabetes or hypertension, may decrease the time available during the medical visit for attention to preventive care.
Patient concerns about being disparaged by physicians and/or medical staff because of their weight may also be an issue in the lack of preventive services for obese patients, because this fear may decrease patients' willingness to seek medical care. Obese patients, particularly those considered to be extremely obese, have reported being treated with disrespect by physicians and other medical staff.8,9 Even among less severely obese women participating in weight loss trials whose mean BMI of 35.2 was less than the mean BMI in some previous studies, 13.2 percent reported that physicians said critical or insulting things about their weight at least sometimes, and 22.5 percent reported that they were at least sometimes treated with disrespect because of their weight.10
Results of a recent study11 about family physician attitudes regarding patients who are obese indicate that 38.5 percent attributed lack of willpower as one of the most significant contributors to their patients' obesity. It is not surprising, therefore, that 12.7 percent of women in one study5 reported delaying or canceling a physician appointment because of their weight concerns. Concern about negative attitudes of the health care staff may be a particular impediment to examinations (e.g., breast examination) that involve disrobing and direct patient contact. Reluctance to seek care may also arise from patients' self-consciousness about their obesity, or concerns about having gained weight or not having lost weight since a previous visit.
Physicians should address obesity as an independent health risk. Guidelines from the National Institutes of Health2 on the identification, evaluation, and treatment of adult obesity provide evidence-based guidance. Nonetheless, physicians may also need guidance on addressing the special health care needs of patients who are overweight or obese. The purpose of this article is to provide guidance on ways to optimize the medical care of these patients, independent of recommendations for weight loss treatment.
Access to Care
To provide the best possible medical care for patients who are overweight or obese, it is helpful to create an office environment that is accessible and comfortable for these patients. This includes educating staff about being respectful to patients regardless of body weight or size, and having appropriate equipment and supplies available (Table 2).12,13
It is useful to have one or two sturdy, armless chairs and/or firm and high sofas (“high” meaning not low to the ground) in the waiting room, not only for those patients who are extremely obese, but also for older patients who have difficulty with mobility. Wide examination tables, bolted to the floor or wall (if possible), ensure that the table does not tip over when the patient sits on one end.
|Office supplies and equipment
|Sturdy, armless chairs and high, firm sofas in waiting room
|Sturdy, wide examination tables, preferably bolted to floor to prevent tipping
|Extra-large examination gowns
|Split lavatory seat and specimen collector with handle
|Large adult blood pressure cuffs and thigh cuffs
|Extra-long phlebotomy needles and tourniquets
|Large vaginal speculae
|Scales with adequate capacity for obese patients (e.g., >350 lb) are preferable.
|Situate the scale in a discrete, private location.
|If weight is related to patient's medical condition, ask whether patient wishes to discuss weight; weight need not be measured at each visit if unrelated to presenting complaint (e.g., sore throat).
|If obtaining the patient's weight is appropriate, weigh patient privately and record weight without comment.
Appropriate-sized examination gowns can also make patients feel more comfortable and are available through many suppliers. A sample listing of catalogs with medical supplies and equipment is provided on page 86. Other easily obtained and useful equipment includes large tourniquets, longer needles for phlebotomy, oversized vaginal speculae and a split toilet seat for urine collection.
Accurate measurement of blood pressure requires special consideration. A standard-sized blood pressure cuff should not be used on persons with an upper-arm circumference of more than 34 cm. Large arm cuffs or thigh cuffs can aid in an accurate determination of blood pressure. If the upper arm circumference exceeds 50 cm, the American Heart Association14 recommendations suggest using a cuff on the forearm and feeling for the appearance of the radial pulse at the wrist to estimate systolic blood pressure. The recommendations note that the accuracy of forearm measurement has not been validated.14
Weighing patients who are overweight and obese demands particular sensitivity. Some patients report avoiding medical care because of fears of being weighed and because of their concerns about negative comments that are sometimes made.9 In addition, standard office scales (which often have a maximum weight of 300 lb) may preclude obtaining accurate weights for those patients who exceed 300 lb. Office scales that can weigh patients of 500 lb or more are readily available.
Physicians may also wish to discuss the patient's feelings about the measurement of weight, and it may be preferable to negotiate how often an accurate weight should be obtained for the patient's medical care. It may not be necessary to obtain a weight measurement, for example, on a patient presenting for evaluation and treatment of a sore throat. If the physician believes that the patient's condition is caused or exacerbated by weight, the physician should ask the patient if he or she would like to discuss weight.15
Sensitivity in word choice may also be helpful. Patients may respond extremely negatively to use of the term obesity, but be more amenable to discussion of their difficulties with weight or being overweight. When weighing is appropriate, it is helpful to do so in a private area (if the scale is in a hallway, a screen or curtain can be used) and to record the weight without comment.12
Special Health Needs of Patients Who Are Extremely Obese
The barriers and limitations in access to care experienced by persons who are extremely obese are unfortunately present in the context of the greater need for health care. Evidence indicates that persons with a BMI of 40 or more have a substantially increased risk for death, and not uncommonly, are not only at risk for illness but are already ill.2
The array of diseases affected by excess body weight is large and is addressed in detail in another report.4 For example, there is a relationship between increased body weight and the development of diabetes, degenerative joint disease and sleep apnea, but this relationship is even more pronounced as the level of obesity increases. The relationship between extreme obesity and diabetes is especially strong. Results of studies have determined the excess risk of diabetes associated with a BMI of more than 35 to be between eight to 30 times that of persons of normal weight.2 Consequent to the increased medical risks and problems associated with extreme obesity, it is especially important that obesity-related risk factors be monitored in these patients.16,17 Table 32,16–18 describes some of the medical conditions for which patients, in any of the three categories of obesity, are at increased risk, along with suggested monitoring.
|Type 2 diabetes
|Polyuria, polydipsia, unexplained weight loss
|Fasting blood glucose or oral glucose tolerance test
|Total cholesterol; HDL cholesterol, triglycerides
|Blood pressure with appropriately sized cuff
|Loud snoring; daytime somnolence
|Sleep studies, ENT evaluation if symptomatic
|Pickwickian (alveolar hypoventilation) syndrome
|Hypersomnolence, right-sided heart failure, dyspnea
|CBC (to rule out polycythemia), pulmonary function tests, blood gases
|Often none; hepatomegaly
|Liver enzymes, ultrasound, or biopsy if indicated
Elevated risks of diabetes, hyperlipidemia, and ischemic heart disease lead to the need for regular monitoring for hyperglycemia and dyslipidemia, as well as a need to carefully assess symptoms of coronary ischemia. Non-alcoholic steatohepatitis is also more common in patients who are obese, especially those with insulin resistance, and may lead to eventual hepatic fibrosis.18
Some additional medical conditions are particularly associated with extreme obesity and may go unrecognized in the clinic. These conditions include lower extremity edema, thromboembolic disease, sleep apnea, and a particular form of respiratory insufficiency known as Pickwickian syndrome.19–24 Clinical presentations of dyspnea and edema in extremely obese patients may be incorrectly assumed to be caused by underlying ischemic damage of the left heart. Although ischemic heart disease does occur with greater frequency in obese persons, dyspnea and edema are common in extremely obese patients even among those without left heart ischemic damage, and may have other underlying causes.2 Respiratory conditions associated with extreme obesity, such as sleep apnea and Pickwickian hypoventilation, also predispose to right-sided heart failure because of elevated pulmonary arterial bed pressures.4 Echocardiography may be useful for evaluating cardiac structure and function in symptomatic patients in whom obesity makes examination difficult.
Shortness of breath or sleep disturbance, for example, may be attributed to the patient's excessive body weight. However, further medical evaluation may point to medical conditions, such as sleep apnea, which, while related to obesity, can be ameliorated even in patients who are unable to lose weight. In addition to potentially life-threatening conditions, extremely obese patients may be troubled by conditions associated with skin compression, such as intertrigo and venous stasis ulcers. Patients who have diabetes are at special risk for fungal infections. Attention to foot care is also important for the extremely obese patient who may have difficulties with reach. Referral to a podiatrist may be indicated in some obese patients and is especially important for those with diabetes.
Improving Health in the Absence of Weight Loss Treatment
Although weight loss should be discussed as a potential treatment for weight-related medical conditions (e.g., hypertension, diabetes, osteoarthritis), treatment of obesity-related risk factors or illnesses—even in the absence of weight loss—is important because not all patients are able or willing to attempt weight loss. Among these patients, physicians can always encourage avoidance of further weight gain. Such a strategy can limit the accumulation of additional medical risks associated with increased weight gain. Health-related behaviors, such as healthful eating and physical activity, can be highlighted as a means to improve health, independent of weight loss.
Fitness may ameliorate many of the cardiovascular health risks associated with overweight and obesity.25,26 Although obese patients may be reluctant to engage in physical activity because of discomfort or embarrassment, physicians can encourage slow, gradual increases in physical activity (e.g., walking with a friend for 10 minutes a day, parking the car farther away in the parking lot). A brochure entitled “Active at Any Size,” written for very large persons and containing tips for becoming more active, is available from the Weight-Control Information Network at 1-877-946-4627 or e-mail: email@example.com.
Preventive Care and Health Counseling
Because obese patients frequently have associated health problems and are likely to be seen for ongoing treatment of these illnesses, physicians may be less likely to think about and to recommend preventive care. It is also true that barriers exist to adequate physical examination in extremely obese patients, and that adequate palpation of abdominal and pelvic organs may be difficult, if not impossible, in some patients. Research is needed to determine the efficacy and cost-effectiveness of alternative means for detecting conditions not amenable to physical examination because of a patient's body habitus. However, recommended preventive evaluations, including Pap smear, physician breast examination and mammography in women, prostate examination in men and stool testing for occult blood can be performed in patients of all sizes. The realization that obese patients suffer disproportionately from some illnesses that are amenable to early detection should increase the priority for performing preventive evaluations and for sensitively addressing concerns with patients who may initially be reluctant to undergo appropriate testing.
Issues of self-esteem and self-acceptance are of particular importance to obese patients. Physicians may be concerned that encouraging self-acceptance in obese patients will undermine efforts aimed at producing weight loss that can significantly improve health. Self-acceptance, however, need not imply complacency or the failure to heed well-founded advice about reducing the health risks of obesity. Conflict need not exist between greater self-acceptance and efforts to make necessary dietary and exercise changes. A more constructive view is to focus on promoting self-acceptance and lifestyle changes aimed at improving health behaviors.
Encouraging patients to lead as full and active a life as possible, regardless of their body weight or success at weight control, may help patients make positive changes such as increasing physical activity.27 Some obese patients find support groups helpful for increasing self-esteem and enhancing commitment to a healthier lifestyle.
Books and Catalogs That Include Medical and Other Supplies for Obese Persons
Amplestuff: Make your world fit you (catalog). P.O. Box 116, Bearsville, N.Y. 12409. Telephone: 1-845-679-3316; fax: 1-845-679-1206; Web site:http://www.amplestuff.com; e-mail: firstname.lastname@example.org. Catalog includes medical items, such as large-sized hospital gowns, blood pressure cuffs, etc., as well as a variety of products for home and travel.
Size Wise. Judy Sullivan; Avon, 1997. 800-238-0658. Includes a health chapter that explains where to find medical equipment for large patients. A Web site with many links can be found at:http://www.sizewise.com.
Some Groups and Organizations Offering Support and/or Information for Large Persons
American Obesity Association
1250 24th Street, N.W., Suite 300
Washington, D.C. 20037
Council on Size and Weight Discrimination
P.O. Box 305
Mount Marion N.Y. 12456
National Association to Advance Fat Acceptance
Sacramento, CA 95818
Weight Control Information Network (WIN)
This network is an information service of the National Institute of Diabetes and Digestive and Kidney Diseases. WIN provides printed materials in brochure form and on the Internet about obesity and its treatment, including a brochure on exercise for large patients.