Obesity is a national phenomenon that affects every facet of the delivery and the reception of health care. Orthopedic surgeons are not immune to these influences. This article discusses the social and physical environment in which orthopedic surgeons evaluate obese patients. Special attention should be paid in both the inpatient and outpatient arenas to the different emotional and physical needs with which obese patients present in contrast to their lean counterparts.
Obesity as a medical condition is currently at historic epidemiologic levels and is rising. It has been proven to affect nearly every facet of medical care from the delivery of this care to its reception. Patients who are obese present novel challenges to each and every surgeon. Historically, these patients and their body habitués were anomalies whose orthopedic care admittedly differed from that of their lean counterparts for a variety of reasons. With the current national trends in obesity, however, this segment of the population has increased dramatically. Overweight and obese patients will increasingly seek routine, traumatic, urgent, and emergent orthopedic care and every orthopedic surgeon should be adequately prepared to treat overweight and obese patients.
Epidemiology
Obesity has come to be clinically and epidemiologically defined by one’s body mass index (BMI). A person’s BMI is calculated by dividing his or her weight as measured in kilograms (kg) by the square of his or her height, measured in meters (m 2 ). Table 1 shows the categories of BMI. A healthy BMI range is 18.5 to 24.9 kg/m 2 . Overweight is defined as a BMI from 25.0 to 29.9 kg/m 2 and obesity is defined as BMI of 30 kg/m 2 or greater. Obesity can further be subdivided based on subclasses of BMI, as shown in Table 1 . Extreme obesity is defined as a BMI greater than 40 kg/m 2 . The World Health Organization (WHO) recently stated that obesity has reached epidemic proportions all over the world. WHO estimates that more than 1 billion adults worldwide are overweight and 300 million of those people are obese. Obesity levels vary widely among nations with a prevalence of less than 5% in China, Japan, and certain African nations and a prevalence of greater than 75% in urban Samoa. Even in countries with a low overall obesity rate, this rate can approach 20% in their more urban cities. Seemingly, as the income, technology, and quality of lives of a particular group of people increase, so does the obesity rate.
| Class | BMI (kg/m 2 ) | |
|---|---|---|
| Underweight | <18.5 | |
| Normal weight | 18.5–24.9 | |
| Overweight | 25.0–29.9 | |
| Obese | I | 30.0–34.9 |
| II | 35.0–39.9 | |
| Extreme Obesity | III | ≥40.0 |
In the United States, there has been a dramatic rise in obesity rates since the 1980s. Between 1980 and 2004 the prevalence of obesity more than doubled in American adults. The most recent national estimates from the National Health and Nutrition Examination Survey (NHANES) 2007–2008 suggest that 68% of the American population is overweight and nearly 34% are obese. The greatest relative increase over time has been in the proportion of severely obese individuals. The percentage of the population with a BMI of 40 or greater has increased from 0.9% in the 1960s to its current percentage of about 6%. Mexican American and non-Hispanic black women currently have the highest rates of obesity (BMI ≥30) at 45% and nearly 50%, respectively. The prevalence of obesity is greater than 30% in all ethnic groups, however, and in almost all age and gender subgroups of US adults.
As of 2008, the Centers for Disease Control and Prevention (CDC) estimates that only 1 of the 50 states (Colorado) has an obesity rate under 20%. Although Mississippi is the perennial leader in obese statistics with nearly 33% of its population being obese, there are 5 additional states with an incidence of obesity equal to or greater than 30%. Flegal and colleagues recently interpreted results of the NHANES 1999–2008 that examine national obesity trends. The investigators have concluded that the increases in the prevalence of obesity previously observed do not appear to be continuing at the same rate as in past years. Obesity rates have increased by only about 5% in men and have remained largely statistically stagnant in women over the past decade. They determined that the obesity rate among all adult women was 35.5% and the rate among men was 32.2% in 2008. Thus, depending on the practice location and focus, today’s orthopedic surgeon can expect that at least one third or more of their patient population will be obese and there is no indication that rates of obesity are decreasing.
Weight bias in the health care setting
Although the past several decades have seen tremendous gains in the previously pervasive stigmas surrounding race, religion, and sexuality, these advances have not yet reached weight bias. Recent evidence suggests weight discrimination is highly prevalent in American society and has increased by 66% over the past decade. The prevalence of weight discrimination is now thought to be comparable with that of race discrimination. As an example, Latner and colleagues comparatively researched biases held by nearly 400 university students toward “Muslim,” “fat,” or “gay” individuals. In reviewing their data, the investigators were able to conclude that weight bias is significantly more pervasive than the other biases within the study population. Despite the shame and prejudice induced by the weight stigma, there is a perception that weight stigmatization is justifiable and may motivate individuals to adopt healthier behaviors. Rather, Puhl and Heuer have concluded that stigmatization of obese individuals poses serious risks to their psychological and physical health, generates health disparities, and interferes with implementation of effective obesity prevention efforts.
Research is accumulating that obese individuals experience weight stigma in the health care setting, and that this bias may undermine obese patients’ opportunity to receive effective medical care. In a recent review of the English literature with its focus being the perceived attitude of nurses toward obese patients, the investigators concluded that some nurses held a perception of physical and social unattractiveness of obese patients. The obese patients were at times seen to be emotionally and physically demanding. A number of negative stereotypes were held about the obese individuals, including a belief that they were disproportionately lazy and self-indulgent. Studies have also suggested that the weight of patients significantly affects how medical providers might treat them. Providers may spend less time with obese patients and may provide less health education to these patients as compared with thinner patients. More than half of the 620 primary care doctors questioned in a study by Puhl and Brownell described obese patients as “awkward, unattractive, ugly, and unlikely to comply with treatment.” It is therefore not surprising that obese individuals frequently report experiences of weight bias in health care.
The data presented suggest that a critical need in the treatment of the obese orthopedic patient lies in the realm of sensitivity and understanding. Orthopedic surgeons are ill-equipped to address the multifactorial nature of these challenges. Kristeller and Hoerr evaluated physician biases toward obese patients comparatively across 6 subspecialty fields. The results of their survey suggested that orthopedic surgeons were generally regarded as less interested in taking on any responsibility for patient weight loss management and were the least likely to provide any active intervention. Despite this, a number of orthopedic surgeons in elective practices have informal policies that encourage preoperative weight loss in potential operative candidates. A thorough search of the literature failed to find any scientific basis for this policy. There are a number of studies in the bariatric surgery literature that point to a clear benefit from preoperative weight loss in perioperative surgical parameters (ie, blood loss and surgical time), ease of surgery, and postoperative weight loss. Results of studies like these, however, should be cautiously extrapolated to nonbariatric weight-loss surgery. Moreover, in light of the overwhelming literature that presents obese patients as a segment of society that feels continuously ostracized, an approach such as this may further degrade the health care provider–to-patient relationship. Efforts may be better served to provide an environment that allows the obese patient to feel welcomed and integrated into the mainstream patient population.
Our population of patients continues to age and to grow in any of a number of weight metrics. Kaminsky and Gadaleta suggest that the medical community as a whole is seemingly prepared for the elderly, but not for the obese. They note that the absence of having the simplest and most basic of medical equipment in a size that can accommodate a larger patient can be seen as a significant lack of consideration. One must bear in mind that this occurs in a segment of the population that already harbors feelings of inadequacy, dependence, depression, and overt personality disorders at a rate that exceeds the general population. Obese patients may therefore feel discriminated against, whether intentionally or not, by failures to prepare for their care or failures to recognize their needs during episodes of health care delivery.
To this end, there are some key items that may help to provide an environment for obese patients that may lessen their apprehension and lack of emotional and psychological comfort. An example of a simple intervention that may help to approach a reluctant obese patient and may show some forethought is having a small inventory of examination gowns that will accommodate larger patients that is kept in an area that is readily and discretely accessible.
Weight bias in the health care setting
Although the past several decades have seen tremendous gains in the previously pervasive stigmas surrounding race, religion, and sexuality, these advances have not yet reached weight bias. Recent evidence suggests weight discrimination is highly prevalent in American society and has increased by 66% over the past decade. The prevalence of weight discrimination is now thought to be comparable with that of race discrimination. As an example, Latner and colleagues comparatively researched biases held by nearly 400 university students toward “Muslim,” “fat,” or “gay” individuals. In reviewing their data, the investigators were able to conclude that weight bias is significantly more pervasive than the other biases within the study population. Despite the shame and prejudice induced by the weight stigma, there is a perception that weight stigmatization is justifiable and may motivate individuals to adopt healthier behaviors. Rather, Puhl and Heuer have concluded that stigmatization of obese individuals poses serious risks to their psychological and physical health, generates health disparities, and interferes with implementation of effective obesity prevention efforts.
Research is accumulating that obese individuals experience weight stigma in the health care setting, and that this bias may undermine obese patients’ opportunity to receive effective medical care. In a recent review of the English literature with its focus being the perceived attitude of nurses toward obese patients, the investigators concluded that some nurses held a perception of physical and social unattractiveness of obese patients. The obese patients were at times seen to be emotionally and physically demanding. A number of negative stereotypes were held about the obese individuals, including a belief that they were disproportionately lazy and self-indulgent. Studies have also suggested that the weight of patients significantly affects how medical providers might treat them. Providers may spend less time with obese patients and may provide less health education to these patients as compared with thinner patients. More than half of the 620 primary care doctors questioned in a study by Puhl and Brownell described obese patients as “awkward, unattractive, ugly, and unlikely to comply with treatment.” It is therefore not surprising that obese individuals frequently report experiences of weight bias in health care.
The data presented suggest that a critical need in the treatment of the obese orthopedic patient lies in the realm of sensitivity and understanding. Orthopedic surgeons are ill-equipped to address the multifactorial nature of these challenges. Kristeller and Hoerr evaluated physician biases toward obese patients comparatively across 6 subspecialty fields. The results of their survey suggested that orthopedic surgeons were generally regarded as less interested in taking on any responsibility for patient weight loss management and were the least likely to provide any active intervention. Despite this, a number of orthopedic surgeons in elective practices have informal policies that encourage preoperative weight loss in potential operative candidates. A thorough search of the literature failed to find any scientific basis for this policy. There are a number of studies in the bariatric surgery literature that point to a clear benefit from preoperative weight loss in perioperative surgical parameters (ie, blood loss and surgical time), ease of surgery, and postoperative weight loss. Results of studies like these, however, should be cautiously extrapolated to nonbariatric weight-loss surgery. Moreover, in light of the overwhelming literature that presents obese patients as a segment of society that feels continuously ostracized, an approach such as this may further degrade the health care provider–to-patient relationship. Efforts may be better served to provide an environment that allows the obese patient to feel welcomed and integrated into the mainstream patient population.
Our population of patients continues to age and to grow in any of a number of weight metrics. Kaminsky and Gadaleta suggest that the medical community as a whole is seemingly prepared for the elderly, but not for the obese. They note that the absence of having the simplest and most basic of medical equipment in a size that can accommodate a larger patient can be seen as a significant lack of consideration. One must bear in mind that this occurs in a segment of the population that already harbors feelings of inadequacy, dependence, depression, and overt personality disorders at a rate that exceeds the general population. Obese patients may therefore feel discriminated against, whether intentionally or not, by failures to prepare for their care or failures to recognize their needs during episodes of health care delivery.
To this end, there are some key items that may help to provide an environment for obese patients that may lessen their apprehension and lack of emotional and psychological comfort. An example of a simple intervention that may help to approach a reluctant obese patient and may show some forethought is having a small inventory of examination gowns that will accommodate larger patients that is kept in an area that is readily and discretely accessible.
Office special needs
Obesity-related durable goods might result in significant capital expense. They may, however, prove to be invaluable during the assessment of obese patients and essential to providing for the needs of these individuals. Blood pressure assessment is nearly ubiquitous as a component of new patient examinations in the orthopedic outpatient setting. For patients who are obviously above or below the “average” weight, the standard cuff likely already attached to the sphygmomanometer may not be appropriate. The rise in obesity among our population has resulted in a necessary rise in the arm circumferences of the routine patient. Graves and colleagues evaluated the NHANES data looking specifically at changes in the arm circumferences of the participants. They concluded that the average arm circumference is statistically increasing in size and that this difference is likely attributable to our increasing obesity rates. The investigators predicted that nearly 1 in 4 adults were no longer able to have their blood pressure taken with a standard adult cuff. The official guidelines for blood pressure cuff sizing suggests that a standard adult cuff (ie, 16 × 30 cm) can be used for arm circumferences 27 to 34 cm. For arm circumferences 35 to 44 cm, a large adult cuff (16 × 36 cm) should be used and for arm circumferences 45 to 52 cm, an adult thigh cuff (16 × 42 cm) should be used. It stands to reason that having alternatively sized blood pressure cuffs readily available and seemingly in routine use may promote an environment that suggests a simple acceptance of the obvious physical differences that the obese body habitus presents.
One of the most critical durable goods in the orthopedic outpatient setting is the wheelchair. Patient ambulation is often impaired by injury, ailment, or iatrogenic causes. As the population has grown more obese, so too have their central or truncal dimensions. Between 1988 and 1994 and 2003 and 2004, Li and colleagues calculated that the mean American waist circumference had increased from 96.0 cm to 100.4 cm among men ( P <.001) and from 89.0 cm to 94.0 cm among women ( P <.001). The investigators furthermore deduced that more than one-half of US adults had abdominal obesity in the period of 2003 to 2004 with the criteria for abdominal obesity having been established as waist circumferences greater than 102 cm and 88 cm respectively for men and women. These changes necessarily require a larger wheelchair to accommodate the girth of our larger Americans with waist circumferences above the mean. Although the International Standards Organization (ISO) governs wheelchair manufacturing, the details of sizing are quite variable. The wheelchair industry has arrived at a standard seating width of 18 in. This is very similar to the 17-in standard seat width of most major American airlines. To allow adequate room on either side of the seated patient for comfort, 14-in may represent a maximum patient diameter or width for standard chairs. This would clearly alienate a not so insignificant number of possible patients and inconvenience even more. In contrast, bariatric equipment manufacturers make wheelchairs in widths that surpass a 32-in seating area. Having readily available wheelchairs with expanded seating widths will again aid in providing an environment in which an obese patient may feel welcome. One must exercise some caution, however, because existing interior doorways may allow passage of only 30-in and exterior doorways may maximally allow a 36-in width. For new construction or renovations, the Americans with Disability Act Accessibility Guidelines state that the minimum required width for hallways to safely allow passage of a standard wheelchair must be 36-in continuously with 32-in allowed at any one point (ie, door jamb). Again, however, these measurements are based on a standard-sized wheelchair with a standard seating width of 18-in. The increasing space needs of obese patients and the wheelchair sizes that they require necessitate wider hallways and doorjambs.
Although professional office furniture standards and codes will undoubtedly differ between cities and regions, there are some general themes that one can incorporate that may help to promote a more receptive and safer office environment for the obese patient. Seating surfaces have generally been constructed with the average lean American as the target consumer. In an ambulatory office setting, chairs without arms and loveseats can comfortably accommodate a wide range of body habitus without stigmatizing the occupant.
Once a patient is in the examination room, health care providers should have some confidence that the examination table will support the heaviest of patients. Examination table manufacturer Web sites may have useful information about the weight limits of their products. Additionally, examination tables that have overhangs or “lips” may need to be bolted to the floor to prevent them from tipping over with the eccentric load imposed by obese patients with their initial attempts to sit on it. A useful recommendation for providers that have input into the design of new or renovated outpatient care areas may be to designate a single room for the evaluation of the challenging patient. This challenge may not be imposed by just the weight of the patient but also by patients confined to a stretcher, some elderly patients, combative patients, or difficult patients who require significant assistance otherwise. This room can be equipped with an extra-wide examination table that has been properly secured, larger gowns, and larger blood pressure cuffs and the doorway can be made with an opening of at least 36 in to accommodate stretchers and extra-wide wheelchairs alike. Additionally, this same forethought can be exercised in designing or redesigning one of the facility’s restrooms to have reinforced safety bars and an elevated commode that can be used by obese patients, elderly patients, and patients with limited mobility.
When taken as a whole, recommendations to assist in the outpatient care of obese patients have as their goals promoting an environment in which obese patients feel comfortable presenting and contributing to their care and an environment that promotes the safe and complete evaluation of the patient in question ( Table 2 ). This can be obtained with foresight, an understanding of the limits of currently owned medical devices and paraphernalia, and a willingness to entertain products that will accommodate the larger American body habitus when the need for new equipment and durable goods arises.
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