Medical Care for Patients with Obesity

U.S. Department of Health Medical Care for and Human Services Patients with Obesity

WIN Weight-control Information Network More than one-third of adults in the United States are obese. The U.S. “Helping patients Government views obesity as one of the most severe health concerns facing the nation. With so many people struggling with obesity, almost to overcome all health care providers can expect to care for patients who are obese. This fact sheet offers helpful tips for health care providers to overcome their sense of the challenges unique to providing optimal care to these patients, no matter what weight-loss treatment is used. shame when What Is Obesity? it comes to “Obesity” refers to an excess amount of body fat. It develops when the discussing number of calories (energy) consumed in food and beverages exceeds the number of calories that the body burns to function. There are few food and healthy studies in humans that link direct amounts of total body fat to sickness and death. There are also no formal standards issued by the National eating may Institutes of Health (NIH) that define obesity based on the amount or percentage of a person’s total body fat. A common way to screen for be hard—the obesity is the body mass index. most helpful What Is the Body Mass Index? action is to listen The Body Mass Index (BMI) is a tool used to measure weight as it relates to height. BMI has its limits. It does not assess body fat or and establish a muscle directly. BMI is measured by dividing a person’s weight in pounds by height in inches squared and multiplying by 703. sense of trust.”

Men and women can have the same BMI but different body fat percentages. As a rule, women usually have more body fat than men. —A health care A bodybuilder with large muscle mass and low body fat may have the same BMI as a person who has more body fat. However, a BMI of 30 provider or higher usually suggests excess body fat.

The NIH currently defines overweight as a BMI of 25 to 29.9 and obesity as a BMI greater than or equal to (≥) 30. Obesity is further broken down into Class I (BMI of 30 to 34.9), Class II (BMI of 35 to 39.9), and Class III (BMI ≥ 40) or “extreme obesity.” (See BMI table on page 7.) An online tool for measuring BMI is available at http://www.nhlbi.nih.gov/health/educational/lose_wt/BMI/bmicalc.htm. Here are some issues What Are Some of the Challenges to Treating Patients with Obesity? that may prevent Patients with obesity may delay seeing a health care provider for patients with obesity routine medical care. They may also be less likely to receive certain health tests, such as Pap smears, breast exams, and pelvic exams. Lack from seeking help: of routine medical care is most likely the result of both patient and provider factors. Both the patient and the health care provider play a ■ Being ashamed role in the health of the patient. or embarrassed about their How Can Health Care Providers Offer Optimal weight Medical Care to Patients with Obesity? Health care providers can take steps to make sure that their patients ■ Hearing hurtful receive quality care. Health care providers should do the following:

comments that ■ Treat patients with respect. the health care provider or staﬀ ■ Have suitable equipment and supplies on hand to improve patient access to care. may say about their weight ■ Support healthy behaviors and self-acceptance even if the patient does not wish to lose weight or cannot successfully lose weight. ■ Being disrespected by staﬀ or health To create a positive office climate, medical and other staff should care providers in review this fact sheet. the past Create a positive, open, and comfortable office space

■ Provide sturdy, armless chairs and high, firm sofas in waiting rooms.

■ Provide sturdy, wide exam tables bolted to the floor to prevent tipping.

■ Provide a sturdy stool or step with handles to help patients climb onto the exam table.

■ Provide extra-large patient gowns.

■ Install a split toilet seat. Provide a specimen collector with a handle.

■ Provide reading materials in the waiting room that focus on healthy habits, rather than physical looks or being “thin.”

2 Use medical devices that can correctly assess patients Here are some issues with obesity

■ Use large adult blood pressure cuffs or thigh cuffs on patients that may prevent a with an upper-arm circumference greater than 34 cm. health care provider ■ Use extra long needles to draw blood and have large vaginal specula on hand. from providing the ■ Have a weight scale with the capacity to measure patients who weigh more than 400 pounds. best care to patients Be respectful when talking about the patient’s weight who are obese: ■ Weigh patients in a private area and only when medically needed. ■ Lack of suitable ■ Record weight without comments. medical tools to correctly assess ■ Ask patients if they want to discuss their weight or health. and treat patients ■ Avoid using the term “obesity.” Your patients may prefer such terms as “ BMI” or “weight.” Ask your patients what terms they would like you to use when discussing their weight. ■ Lack of training in providing the Track and test for the following health problems linked to obesity: physical and emotional support ■ type 2 diabetes that patients may ■ hypertension (high blood pressure) need

■ sleep apnea (when breathing pauses while sleeping) ■ Belief that a ■ nonalcoholic steatohepatitis (fatty liver disease) patient’s weight is ■ lower extremity edema (swelling of the legs and feet) mainly due to lack ■ skin compression (ulcers) of willpower

Offer well-care services ■ Challenges ■ Allow enough time during office visits to provide well-care services. performing exams, such as pelvic ■ Suggest or provide such services as Pap smears, breast exams, exams, due to a mammography, prostate exams, and stool testing. patient’s size

3 “My doctor talks Promote healthy behaviors ■ Ask your patients if they would like to talk about weight loss. about nutrition If they want to talk about losing weight, let them know that a and what to eat weight loss of 5 to 7 percent of body weight may lower their chance of developing diabetes. Work with your patients to for my type, but establish realistic goals. ■ Start small. Encourage patients to start with simple goals such not about dieting. as walking for 10 minutes, three times a day. Once they achieve this goal, they can build on it. She encourages ■ Offer patients information and referrals to registered dietitians, exercise, but doesn’t other health providers, and support groups, as needed. ■ Promote self-acceptance and encourage patients to lead full and push. I have been active lives. able to make Health care providers have the power to help improve the lives of patients with obesity. Changes that foster respect for the patient and beneficial changes a supportive and well-designed space for receiving services are within reach of most health care providers. The suggestions outlined in this in my diet under fact sheet offer a solid starting place. Additional resources to help achieve these changes are listed at the end of this fact sheet. her nonjudgmental Research guidance. She is very The National Institute of Diabetes and Digestive and Kidney Diseases respectful. . . . My (NIDDK) conducts and supports a broad range of basic and clinical obesity research. More information about obesity research is available at comfort seems to be http://www.obesityresearch.nih.gov. a goal for her. ” Clinical trials are research studies involving people. Clinical trials look at safe and effective new ways to prevent, detect, or treat disease. Researchers also use clinical trials to look at other aspects of care, —A patient such as improving the quality of life for people with chronic illnesses. To learn more about clinical trials, why they matter, and how to participate, visit the NIH Clinical Research Trials and You website at http://www.nih.gov/health/clinicaltrials. For information about current studies, visit http://www.ClinicalTrials.gov.

4 Additional Information for Health Care Providers Changes that Davis NJ, Shishodia H, Taqui B, Dumfeh C, Wylie-Rosett J. Resident physician attitudes and competence about obesity treatment: need foster respect for for improved education. Medical Education Online. 2008;13:5. Available at http://www.med-ed-online.net/index.php/meo/article/ the patient and download/4475/4655. Accessed March 2011. a supportive and Huizinga MM, Cooper LA, Bleich SN, Clark JM, Beach MC. Physician respect for patients with obesity. Journal of General Internal well-designed Medicine. Nov 2009;24(11):1236–1239. Available at http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2771236/?tool=pubme. space for receiving Accessed March 2011. National Heart, Lung, and Blood Institute, NIH. Body Mass Index services are Tables. http://www.nhlbi.nih.gov/guidelines/obesity/bmi_tbl.htm. Accessed June 2011. within reach of National Task Force on the Prevention and Treatment of Obesity. Medical care for obese patients: advice for health care professionals. most health care American Family Physician. 2002;65(1):81–88. Available at http://www.aafp.org/afp/2002/0101/p81.html. Accessed March 2011. providers. Shay LE, Shobert JL, Seibert D, Thomas LE. Adult weight management: translating research and guidelines into practice. Journal of the American Academy of Nurse Practitioners. Apr 2009;21(4):197– 206. Available at http://onlinelibrary.wiley.com/doi/10.1111/ j.1745-7599.2008.00383.x/full. Accessed March 2011.

Medical Supplies and Equipment Amplestuff: Make Your World Fit You (Catalog) Department WS P.O. Box 116 Bearsville, NY 12409 Phone: 845–679–3316 Toll-free number: 1–866–486–1655 Email: [email protected] Internet: http://www.amplestuff.com

Additional Reading from the Weight-control Information Network The following publications are available online at the addresses listed in each description and also by calling WIN toll-free at 1–877–946–4627. Active at Any Size explains the benefits of regular physical activity and describes activities that people who are overweight or obese can enjoy safely (available online at http://www.win.niddk.nih.gov/publications/ active.htm).

5 “My doctor never Bariatric Surgery for Severe Obesity explains how this operation on the stomach and/or intestines helps patients with extreme obesity to lose judges me on my weight. Patients may use this fact sheet to talk about this option with their health care providers. This fact sheet explains which patients might choose this option and describes the different types of bariatric surgery weight and never (available online at http://www.win.niddk.nih.gov/publications/gastric.htm). talks down to me Just Enough for You: About Food Portions explains the difference between a portion and a serving, and offers tips to help readers choose about it.” healthy portions (available online at http://www.win.niddk.nih.gov/ publications/just_enough.htm). —A patient Talking With Patients About Weight Loss: Tips for Primary Care Professionals offers ideas for speaking respectfully with patients about overweight and obesity and helping them set and maintain goals. It includes a tear-off sheet with tips and resources (available online at http://www.win.niddk.nih.gov/publications/talking.htm). Walking … A Step in the Right Direction explains how to start a walking program, presents a sample program, and shows stretches for warming up and cooling down (available online at http://www.win.niddk.nih.gov/publications/walking.htm).

Additional Information for Patients American Association of Diabetes Educators 100 West Monroe Street, Suite 400 Chicago, IL 60603 Phone: 1–800–338–3633 Email: [email protected] Internet: http://www.diabeteseducator.org Locate a certified diabetes educator (C.D.E.). American฀Academy฀of฀Nutrition฀and฀Dietetics 120 South Riverside Plaza, Suite 2000 Chicago, IL 60606–6995 Phone: 1–800–877–1600 Email: [email protected] Internet: http://www.eatright.org Locate a registered dietitian (R.D.). National Diabetes Information Clearinghouse 1 Information Way Bethesda, MD 20892–3560 Phone: 1–800–860–8747 Email: [email protected] Internet: http://www.diabetes.niddk.nih.gov Find health information and publications on diabetes.

6 The number at the top of column is BMI that height and weight. Pounds have been rounded off. To use the table, find appropriate height in the left-hand column labeled Height. Move across to a given weight (in pounds). Body Mass Index Table The Evidence Report. Evidence The Source: from Adapted (inches) Height BMI 58 64 75 68 61 59 72 65 76 69 62 60 73 66 70 63 74 67 71

1 1 2 2 3 4 4 5 5 6 6 7 8 8 9 9 204 197 192 186 180 174 169 163 157 151 145 140 134 128 122 116 110 5 6 6 7 8 9 0 0 1 2 3 4 4 5 6 7 279 272 264 256 248 240 232 224 216 208 200 192 184 176 168 160 152 2 3 3 4 5 5 6 7 7 8 9 9 0 1 1 2 230 223 216 210 203 197 190 184 177 171 164 158 151 144 138 131 125 0 0 1 1 2 2 3 3 4 4 5 5 6 6 7 8 185 180 174 169 164 158 153 148 143 137 132 127 122 116 111 106 100 4 4 5 6 6 7 8 9 9 0 1 2 2 3 4 5 258 250 242 235 228 221 213 206 199 191 184 177 169 162 154 147 140 1 2 2 3 3 4 5 5 6 6 7 8 8 9 9 0 210 204 198 192 186 180 174 168 162 156 150 144 138 132 126 120 114 5 6 7 8 8 9 0 1 2 3 3 4 5 6 7 7 287 279 271 263 254 246 238 230 221 213 205 197 189 180 172 164 156 2 3 4 4 5 6 6 7 8 8 9 0 0 1 2 3 236 230 223 216 209 203 196 189 182 176 169 162 155 149 142 135 128 0 0 1 2 2 3 3 4 4 5 5 6 6 7 8 8 191 186 180 175 169 164 158 153 147 142 136 131 126 120 115 109 104 4 5 5 6 7 8 8 9 0 1 1 2 3 4 5 5 265 257 250 242 235 227 219 212 204 197 189 182 174 166 159 151 144 1 2 3 3 4 4 5 6 6 7 7 8 9 9 0 1 216 210 204 198 192 186 179 173 167 161 155 148 142 136 130 124 118 3 3 4 5 6 6 7 8 8 9 0 0 1 2 2 3 243 236 229 222 216 209 202 195 188 181 174 167 160 153 146 139 132 0 1 1 2 3 3 4 4 5 5 6 6 7 8 8 9 197 191 186 180 175 169 163 158 152 146 141 135 130 124 118 113 107 4 5 6 7 7 8 9 0 1 1 2 3 4 4 5 6 272 264 256 249 241 233 225 218 210 202 194 186 179 171 163 155 148 2 2 3 4 4 5 5 6 7 7 8 9 9 0 1 217 211 204 198 191 185 178 172 166 159 153 146 140 134 127 121 3 143 136 92 12 32 52 72 93 13 33 53 73 94 14 34 43 42 41 40 39 38 37 36 35 34 33 32 31 30 29 28 27 26 25 24 23 22 21 20 19 19 0 0 1 1 1 2 2 3 3 4 4 5 5 6 6 17 167 162 158 153 148 143 138 134 129 124 119 115 110 105 100 96 91 49 0 0 1 1 2 2 3 3 4 4 5 5 6 6 7 17 173 168 163 158 153 148 143 138 133 128 124 119 114 109 104 99 94 7121712181318131813181318131814191 179 174 168 163 158 153 148 143 138 133 128 123 118 112 107 102 97 NIH Publication No. 98–4083: Institute; Blood and Lung, Heart, National 1998. Clinical Guidelines on the Identiﬁcation, Evaluation, Identiﬁcation, the on Guidelines Clinical and Treatment Overweight of Adults. in Obesity and omlOewih Obese Overweight Normal 5 5 6 7 7 8 9 0 0 1 2 2 3 4 5 5 265 257 250 243 236 229 222 215 208 200 193 186 179 172 165 157 150

Body Mass Index Table Body Weight (pounds) 2 3 3 4 4 5 6 6 7 8 8 9 9 0 1 1 325 319 312 306 299 293 287 280 274 268 261 255 249 242 236 230 223

0 1 2 2 3 3 4 5 5 6 6 7 7 8 9 9 302 296 291 285 279 273 267 262 256 250 244 238 232 227 221 215 209 8 9 0 1 1 2 3 4 5 5 6 7 8 9 9 0 415 407 399 391 383 375 367 359 351 343 335 327 319 311 303 295 287 3 4 4 5 6 6 7 8 8 9 0 0 1 2 2 3 341 335 328 322 315 308 302 295 289 282 276 269 262 256 249 243 236 9 9 0 0 1 1 2 2 3 3 4 4 5 5 6 6 275 269 264 259 254 248 243 238 232 227 222 217 211 206 201 195 190 6 7 7 8 9 0 0 1 2 3 3 4 5 6 6 7 383 375 368 361 353 346 338 331 324 316 309 302 294 287 279 272 265 1 2 2 3 4 4 5 5 6 7 7 8 8 9 0 0 312 306 300 294 288 282 276 270 264 258 252 246 240 234 228 222 216 9 0 1 2 2 3 4 5 6 6 7 8 9 0 1 1 426 418 410 402 394 385 377 369 361 353 344 336 328 320 312 304 295 4 5 5 6 7 7 8 9 9 0 1 1 2 3 3 4 351 345 338 331 324 318 311 304 297 291 284 277 270 263 257 250 243 9 0 0 1 1 2 2 3 4 4 5 5 6 6 7 7 284 278 273 267 262 256 251 246 240 235 229 224 218 213 207 202 196 7 8 8 9 0 1 1 2 3 4 4 5 6 7 7 8 393 386 378 371 363 355 348 340 333 325 318 310 302 295 288 280 272 2 2 3 4 4 5 6 6 7 7 8 9 9 0 0 1 322 315 309 303 297 291 284 278 272 266 260 253 247 241 235 229 223 5 5 6 7 7 8 9 9 0 1 2 2 3 4 4 5 362 355 348 341 334 327 320 313 306 299 292 285 278 271 264 257 250 0 0 1 2 2 3 3 4 4 5 5 6 270 265 259 254 248 242 237 231 225 220 214 208 203 8 8 9 0 1 1 2 334 326 319 311 303 295 287 280 4191419242925202520252025202521262 266 261 255 250 245 240 235 230 225 220 215 209 204 199 194 189 84 7 8 8 9 9 0 0 1 1 2 2 2 3 3 4 4 25 248 244 239 234 229 224 220 215 210 205 201 196 191 186 181 177 2 8 8 9 9 0 0 1 1 2 2 3 3 4 4 5 5 26 257 252 247 242 237 232 227 222 217 212 208 203 198 193 188 183 8 7 7 8 9 0 0 1 2 2 3 4 5 5 6 7 7 386 379 372 365 358 351 343 338 329 322 315 308 301 293 286 279 272 4 5 5 6 7 8 8 9 0 1 420 412 404 396 389 381 373 365 358 350 342 54 74 95 15 354 53 52 51 50 49 48 47 46 45 4 Extreme Obesity Extreme 7 8 8 9 9 304 299 293 287 282 278 3 3 344 338 331 0 314 308 2 431 423 4 354 348 8 285 280 9 397 390 1 324 318 3 443 435 5 365 358 8 295 289 0 408 401 2 334 328 6 376 369 1276 71 258 3 267 2

7 Advocacy and Policy Organizations Weight-control Information Council on Size and Weight Discrimination Network P.O. Box 305 Mount Marion, NY 12456 1 WIN Way Phone: 845–679–1209 Bethesda, MD 20892–3665 Email: [email protected] Phone: 202–828–1025 Internet: http://www.cswd.org Toll-free number: 1–877–946–4627 Fax: 202–828–1028 National Association to Advance Fat Acceptance Email: [email protected] Internet: http://www.win.niddk.nih.gov P.O. Box 4662 Foster City, CA 94404–0662 Phone: 916–558–6880 Internet: http://www.naafa.org http://www.facebook.com/ win.niddk.nih.gov Obesity Action Coalition 4511 North Himes Avenue, Suite 250 The Weight-control Information Network (WIN) is a national Tampa, FL 33614 information service of the National Phone: 800–717–3117 Institute of Diabetes and Digestive Internet: http://www.obesityaction.org and Kidney Diseases (NIDDK), part of the National Institutes of Rudd Center for Food Policy and Obesity Health (NIH). WIN provides the Yale University general public, health professionals, 309 Edwards Street and the media with science-based, New Haven, CT 06520–8369 up-to-date, culturally relevant Phone: 203–432–6700 materials and tips. Topics include how to consume healthy foods Internet: http://www.yaleruddcenter.org and beverages, barriers to physical activity, portion control, and eating The Obesity Society and physical activity myths. 8630 Fenton Street, Suite 918 Silver Spring, MD 20910 Publications produced by WIN are Phone: 301–563–6526 reviewed by both NIDDK scientists and outside experts. This fact sheet Internet: http://www.obesity.org was also reviewed by Rebecca Puhl, Ph.D., Rudd Center for Food Policy and Obesity, Yale University. Special thanks to Lynn McAfee of the Council on Size and Weight Discrimination for providing the patient quotes for this fact sheet. You may also find additional information about this topic by visiting MedlinePlus at http://www.medlineplus.gov.

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This publication is not copyrighted. WIN encourages users of this fact sheet to duplicate and distribute NIH Publication No. 03–5335 as many copies as desired. February 2003 This fact sheet is also available at Updated July 2011 http://www.win.niddk.nih.gov. 8