CIHR Research: Treating the Obese: A Big Issue
Obese patients often try to seek treatment for diseases beyond their weight. Those in the medical community try to provide obese patients with the requested treatment. But do hospitals have the proper equipment to help the medical community with treatment possibilities? Not necessarily.
This stands to be a significant problem for Canadian
hospitals, patients and healthcare workers alike. In 2004, for instance, 23% of Canadian adults were considered obese, with a body mass index of more than 30. The statistics for that year do not get any better: one in four seniors over the age of 75 years was considered to be obese. Eighteen per cent of children aged two to 17 were overweight, while 8% were obese. More importantly, around 2% of the population is now morbidly obese, in that they carry more than 45-68 kg (100-155 lbs) excess weight.
"This problem is actually much bigger than the question of, Do we have the right-sized equipment?" says Dr. Sharma. "Even for the equipment and tests that we do have, we're not sure that these are sensitive or specific enough to accurately diagnose the medical issues of these patients."
According to Dr. Sharma, in any given hospital across Canada, there can be between 10 and 20 morbidly obese patients. However, because body weight is not clearly marked during hospital admissions, the real magnitude of the problem is unclear.
If the available hospital equipment cannot accommodate the needs of morbidly obese patients, there are serious problems at hand for patient care. Nurses could suffer injuries from lifting or moving patients from room to room, wheelchairs may not be large enough to accommodate patients and magnetic resonance imaging (MRI) or ultrasound machines may not provide accurate images of a troubled area for diagnosis.
For these reasons, Dr. Sharma suggested a study for Navneet Singh, one of his graduate students, who assessed the quality and availability of hospital equipment for morbidly obese patients presenting with heart problems at Hamilton General Hospital. Dr. Sharma supervised the progress of Singh's pilot study, with the help of Drs. Heather Arthur, Heart and Stroke Foundation of Ontario Chair in Cardiovascular Nursing, and Andrew Worster, Associate Professor in the Department of Medicine's Division of Emergency Medicine at McMaster University.
Singh's study involved 134 morbidly obese patients and over 40 nurses who were involved in emergency care at the hospital. All participants were interviewed regarding their satisfaction with a variety of standard hospital equipment, including bed sizes, gown sizes, wheelchairs and blood pressure cuffs. The study produced answers that were anticipated - along with some surprising discoveries.
"It was evident that the bigger the patients, the less comfortable they were with the size of the hospital equipment," says Dr. Sharma. "What was most interesting, however, was that the nurses and the patients reported differences in the adequacy of equipment." This difference in perception puts morbidly obese patients at risk, as the study also found that most nurses were not aware of the hospital equipment's weight restrictions or limitations.
In order to improve conditions for these patients, Dr. Sharma proposes three solutions: sensitivity training for medical personnel, the creation of a bariatric coordinator position at hospitals and perhaps an increase in bariatric diagnostic and treatment facilities at Canadian hospitals.
Sensitivity Training for Medical PersonnelNumerous studies show that medical personnel openly discriminate against obese patients. It is no secret that morbidly obese people already have a difficult time in social contexts because they find it difficult to sit down in a movie theatre or an airplane. There are also many issues for the morbidly obese when it comes to medical encounters. For example, as most scales have weight limitations of 160 kg (350 lbs), some patients report being weighed on scales in the loading docks of hospitals. And even waiting room furniture and wall-mounted toilets have been known to break.
"The fact that we have had several toilets break off the wall shows that they're probably nowhere close to where they should be in terms of weight capacity," says Dr. Sharma. "That can cause injuries for patients, and creates a hugely embarrassing situation."
All of this embarrassment can make obese patients reluctant to seek medical care, which delays diagnoses and treatments for them. "This is one of the complaints that you get most often from obese patients," Dr. Sharma says. "They're frustrated and angry at their doctors, because, no matter what health complaint they have, all they hear is that they've got to lose weight. This occurs even without the doctor actually doing any tests or taking a real look to see if the medical problem has anything to do with the patient's weight."
There is little doubt that sensitivity training for medical personnel related to the stigma associated with morbidly obese patients is a step in the direction toward positive change. "Some issues are very simple," Dr. Sharma adds. "When you have morbidly obese patients, for example, you don't ask them to take off their shoes - unless you're sure the patients can put these shoes back on."
In his opinion, while it is important to prevent obesity in the first place, the medical system also has the responsibility to provide proper care to those who are already obese. "My pet peeve in this whole obesity discussion is that we're not providing treatments to those people who have the disease," Dr. Sharma says. "We're not talking about a minority here. We're talking about one-quarter of the adult population and almost a quarter of our children. They already have the disease, and they should be getting treatment; yet, for most, the only option is the commercial weight-loss centre at the strip mall."
Bariatric CoordinatorThe pilot study revealed that there is a lack of understanding about hospital equipment among medical personnel. Dr. Sharma proposes that the creation of a bariatric coordinator position to help alleviate concerns over the location of supersized hospital equipment and other issues related to the care of morbidly obese patients. "The bariatric coordinator would know, for example, where in the hospital you could find supersized wheelchairs or commodes and arrange for special mattresses or access to diagnostic equipment," Dr. Sharma says. Should a morbidly obese patient require larger equipment that is not available at a given hospital (such as an MRI machine), the coordinator would know where this equipment is available and could arrange to transfer the patient to the appropriate facilities.
The coordinator could also create awareness among medical personnel and ensure that there is a friendly and respectful environment to meet the needs of these patients. Joking about obesity would become as much a taboo as joking about race, gender, sexual orientation or disabilities.
Bariatric Diagnostics and TreatmentsGiven the increasing number of morbidly obese patients (an estimated 500,000 across Canada), large medical centres need to ensure that they have the proper equipment and procedures in place to provide proper medical care to these patients. Moreover, there is a need to increase capacity for the delivery of treatments for obesity, including bariatric or weight-loss surgery (often referred to as stomach stapling or gastric bypass). In Ontario, approximately 150,000 people qualify for this kind of surgery. But they currently have to go to the United States to seek treatment and coverage through the Ontario Health Insurance Plan (OHIP). The out-of-country approvals are necessary because surgery options are not readily available in Canada. A few exceptions include Hôpital Laval Research Centre and McGill University Health Centre. However, the volume of operations at these centres is relatively low and the waiting lists are long.
Dr. Sharma feels that the bariatric surgery option needs to expand in Canada. The out-of-country approvals, for instance, cost OHIP between $15 and $20 million a year. Patients who return after surgery do not receive proper follow-up treatment and run the risk for nutritional and other complications.
"For most patients, bariatric surgery is an extremely cost-effective and life-altering intervention," Dr. Sharma says. "Yet we have nothing in the system that will actually provide bariatric surgery to hundreds of thousands of bariatric patients across the country. Who is going to do it? How much is it going to cost? How is it going to be organized?"
Concluding ThoughtsIn order for morbidly obese patients to be treated properly in Canada, it is important for all members of society to understand their needs. In March 2006, Dr. Sharma received federal funding to help make this happen with the formation of the Canadian Obesity Network (CON).
CON, which is funded through the Networks of Centres of Excellence program, gathers the expertise and dedication of more than 1,200 member researchers, healthcare providers and other professionals. All CON members have a unified interest in reducing the mental, physical and economic burden of obesity on Canadians.
"With such a large number of obese or morbidly obese patients in the system, we need to re-evaluate how we deal with them," Dr. Sharma says. "We need to look at things from a human resource perspective, training of personnel to sensitivity issues, accessibility to suitable equipment and reliability and specificity of diagnostic procedures; and we need to know that the treatments we're delivering are actually working in these patients."
For more information about CON, please visit: www.obesitynetwork.ca
About the Author(s)
Peter Maitland is a writer-editor in CIHR's Marketing and Communications Division.
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