Medical Care for Obese Patients

Approximately 32 percent of adults in the United States are obese, up from 23 percent a decade ago. The U.S. Government considers obesity to be one of the most serious health concerns facing the nation. As prevalence rates continue to rise, almost all health care providers can expect to encounter obese patients in their practices. This fact sheet offers practical tips for overcoming the challenges unique to providing optimal care to patients who are obese, independent of weight-loss treatment.

Obesity and Body Mass Index

Body mass index (BMI) closely correlates with body fat in most people and can help predict the development of health problems related to excess weight. BMI is calculated by dividing a person's weight in kilograms by height in meters squared. The mathematical formula is "weight (kg) / height (m²)."

The National Institutes of Health identify obesity as a BMI greater than or equal to 30. Obesity is further broken down to Class I (BMI of 30 to 34.9), Class II (BMI of 35 to 39.9), and Class III (BMI = 40) or "extreme obesity." For more information about calculating BMI, a patient can visit http://nhlbisupport.com/bmi/bminojs.htm.

Challenges in Treating Obese Patients

Patients who are obese may delay seeking medical care. They may also be less likely to receive certain preventive care services, such as Pap smears, breast examinations, and pelvic examinations. Insufficient medical care is probably the result of both patient and physician factors.

Providing Optimal Medical Care to Obese Patients

Health care providers can take steps to overcome barriers to ensure optimal medical care for patients who are obese. Optimal care begins with educating staff about treating patients with respect. Having appropriate equipment and supplies on hand further increases patient access to care. Weighing patients privately and only when necessary may help them overcome their reluctance to seek medical services. Offering preventive services in addition to monitoring and treating ongoing medical conditions helps ensure that obese patients receive the same level of care as nonobese patients. Finally, providers should encourage healthy behaviors and self acceptance even in the absence of weight loss.

Using the following checklist may improve patient care in your office. To create a positive office environment, review the checklist with your medical and administrative staff

Patient barriers to adequate medical care and preventive service include:

• Self-consciousness about weight.
• Fears of disparaging, negative, or inapporopriate comments from physicians and medical staff.
• Weight gain or failure to lose weight since last medical appointment.
• Past negative experiences with or disrespectful treatment from physicians and medical staff.

Create an accessible and comfortable office environment.

• Provide sturdy, armless chairs and high, firm sofas in waiting rooms.
• Provide sturdy, wide examination tables that are bolted to the floor to prevent tipping.
• Provide a sturdy stool or step with handles to help patients get on the examination table.
• Provide extra large examination gowns.
• Install a split lavatory seat and provide a specimen collector with a handle.

Use medical equipment that can accurately assess patients who are obese.

• Use large adult blood pressure cuffs or thigh cuffs on patients with an upper-arm circumference greater than 34 cm.
• Have extra long phlebotomy needles, tourniquets, and large vaginal speculae on hand.
• Have a weight scale with adequate capacity (greater than 350 pounds) for obese patients.

Reduce patient fears about weight.

• Weigh patients only when medically appropriate.
• Weigh patients in a private area.
• Record weight without comments.
• Ask patients if they wish to discuss their weight or health.
• Avoid using the term obesity. Your patients may be more comfortable with terms such as "difficulties with weight" or "being overweight." You may wish to ask your patients what terms they prefer when discussing their weight.

Body Mass Index Table

To use the table, find the appropriate height in the left-hand column labeled Height. Move across to a given weight. The number at the top of the column is the BMI at that height and weight. Pounds have been rounded off.

Source: Clinical Guidelines on the Identification, Evaluation, and Treatment of Overweight and Obesity in Adults, National Institutes of Health, National Heart, Lung, and Blood Institute, September 1998

Monitor obesity-related medical conditions and risk factors.

• Conduct tests to assess type 2 diabetes, dyslipidemia, hypertension, sleep apnea, ischemic heart disease, thyroid disease, and nonalcoholic steatohepatitis as medically indicated.
• Consider concerns of the extremely obese patient that may be overlooked such as lower extremity edema, thromboembolic disease, respiratory insufficiency (Pickwickian syndrome), skin compression (ulcers), and fungal infections.

Offer preventive care services.

• Allow adequate time during office visits for preventive care services.
• Recommend or provide preventive care services such as Pap smears, breast examinations, mammography, prostate examinations, and stool testing.

Encourage healthy behaviors.

• Discuss weight loss—as little as 5 to 10 percent of body weight—as a treatment for weight-related medical conditions. Work with your patient to establish realistic treatment goals.
• Emphasize healthy behaviors to prevent further weight gain, whether or not the patient is able or willing to lose weight.
• Encourage physical activity to improve cardiovascular health.
• Seek professional resources to assist your patients and provide referrals to registered dietitians, certified diabetes educators, exercise physiologists, weight management programs, and support groups, as appropriate.
• Provide printed educational materials and lists of resources to patients. Offering this information may be especially helpful if your time with the patient is limited. Be sure that reading materials appropriately emphasize health rather than thinness.
• Promote self-acceptance and encourage patients to lead a full and active life.

Providing optimal medical care to patients who are obese may be challenging. Changes that foster a supportive and accessible environment for the patient, however, are within reach of most health care providers and can go far to overcome both patient and provider barriers to care.

Health care provider barriers to adequate medical care and preventive services include:

• Lack of appropriate medical equipment to accurately assess and treat patients who are obese.
• Lack of training in accommodating the physical and emotional needs of persons who are obese.
• Perception that patients’ obesity is mainly due to lack of willpower.
• Difficulty performing examinations, such as pelvic exams, due to the patient’s size.
• Focus on treating ongoing medical conditions, to the exclusion of preventive care services.
• Percepetion that a patient’s health is not improved unless she or he looses weight.

Additional Reading From the Weight-control Information Network

Active at Any Size. National Institutes of Health (NIH) Publication No. 04-4352.

Healthy Eating and Physical Activity Across Your Lifespan: Better Health and You. NIH Publication No. 04-4992.

Just Enough for You: About Food Portions. NIH Publication No. 03-5287.

Walking...A Step in the Right Direction. NIH Publication No. 04-4155.

Prescription Medications for the Treatment of Obesity. NIH Publication No. 04-4191

Additional Reading

American Medical Association. Assessment and Management of Adult Obesity: A Primer for Physicians. Available at: www.ama-assn.org/ama/pub/category/10931.html. Updated April 6, 2006. Accessed January 2007.

National Heart, Lung, and Blood Institute, NIH. Clinical Guidelines on the Identification, Evaluation, and Treatment of Overweight and Obesity in Adults. Available at: www.nhlbi.nih.gov.guidelines/obesity/ob_gdlns.pdf. September 1998. Accessed January 2007.

National Task Force on the Prevention and Treatment of Obesity. Medical Care for Obese Patients: Advice for Health Care Professionals. American Family Physician. 2002;65(1):81–88.

Additional Patient Information

"My doctor talks about nutrition and what to eat for my type, but not about dieting. She encourages exercise, but doesn't push. I have been able to make beneficial changes in my diet under her nonjudgmental guidance. She is very respectful...my comfort seems to be a goal for her."

American Association of Diabetes Educators

100 West Monroe Street

Suite 400

Chicago, IL 60603

Phone: 1–800–338–3633

Email: aade@aadenet.org

Internet: www.aadenet.org

Locate a certified diabetes educator (C.D.E).

American Dietetic Association

120 South Riverside Plaza

Suite 2000

Chicago, IL 60606–6995

Phone: 1–800–877–1600

Email: findnrd@eatright.org

Internet: 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: ndic@info.niddk.nih.gov

Internet: www.diabetes.niddk.nih.gov

Find health information and publications on diabetes.

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: amplestuff2@aol.com

Internet: www.amplestuff.com

Advocacy and Policy Organizations

NAASO, The Obesity Society

8630 Fenton Street

Suite 918

Silver Spring, MD 20910

Phone: (301) 563–6526

Internet: www.naaso.org

Council on Size and Weight Discrimination

P.O. Box 305

Mount Marion, NY 12456

Phone: (845) 679–1209

Email: info@cswd.org

Internet: www.cswd.org

National Association to Advance Fat Acceptance

P.O. Box 22501

Oakland, CA 94609

Phone: (916) 558–6880

Internet: www.naafa.org

Rudd Center for Food Policy and Obesity

Yale University

309 Edwards Street

New Haven, CT 06520–8369

Phone: (203) 432–6700

Internet: www.YaleRuddcenter.org

Weight-control Information Network

1 WIN Way

Bethesda, MD 20892–3665

Phone: (202) 828–1025

FAX: (202) 828–1028

Toll-free number: 1–877–946–4627

Internet: http://www.win.niddk.nih.gov

Email: win@info.niddk.nih.gov

The Weight-control Information Network (WIN) is a service of the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) of the National Institutes of Health, which is the Federal Government's lead agency responsible for biomedical research on nutrition and obesity. Authorized by Congress (Public Law 103–43), WIN provides the general public, health professionals, the media, and Congress with up-to-date, science-based health information on weight control, obesity, physical activity, and related nutritional issues.

Publications produced by WIN are reviewed by both NIDDK scientists and outside experts. This fact sheet was also reviewed by Kelly D. Brownell, Ph.D., Rudd Center for Food Policy and Obesity, Yale University, and 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.