Stop telling fat patients to “just try” a too-small blood pressure cuff – Weight Stigma in Practice
Blood Pressure - Part 1
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Note: Today the US Supreme Court stripped people who are or may become pregnant of their basic human right to bodily autonomy. This can have serious and specific impacts on fat patients. As a reminder, I wrote a piece about emergency contraception for higher-weight people that you can find here.
For today, we’re going to talk about blood pressure, in particular when fat people are being told to “just try” a too-small cuff.
This is a pet peeve of mine that I was reminded of when I went to the gynecologist for my well-woman exam a few days ago. The nurse had an adult large blood pressure cuff, which is too small for my arm. I know that from previous experience (the cuff bladder encircles less than 80% of my arm) and from looking up the measurements for the cuff (my arm is bigger around than the recommended tolerances.)
As she tried to put it on my arm I pulled back and told her that the cuff was too small. I asked for a thigh cuff or forearm blood pressure as an option, but she said they didn’t have a thigh cuff as she tried to put the cuff on me again. Again I pulled back. I told her once more that the cuff was too small and, again, offered a forearm blood pressure as an option. Ignoring me she said “let’s just try it” and advanced at me for a third time with the too-small cuff. I finally said “Stop. I decline to have my blood pressure taken.”
I don’t think that this nurse was ill-intentioned, and she’s certainly not alone. This is not the first time this has happened to me and it is a real problem. “Just try it” is a deeply misleading phrase here because it’s not as if a too-small cuff will always give some kind of error message. As the healthcare professional taking my blood pressure should well know, they will likely get a blood pressure reading from a too-small cuff, but the number will be inaccurate. My blood pressure will seem higher than it is.
I’m not sure how many fat people have been mistakenly diagnosed with high blood pressure because of a too-small cuff, but given the number of times (and the persistence with which) a healthcare provider has tried to take my blood pressure even after being told that the cuff is too small (something they should have worked out on their own,) I imagine that it’s not a small number.
This is added to the fact that most healthcare providers aren’t typically doing all the things they should be to get an accurate blood pressure (making sure the patient is calm and relaxed, that they are seated with back supported and legs uncrossed, that their arm is supported at heart level, that neither patient nor practitioner is talking during the reading.)
Not to mention that the trauma of past weight stigma that many fat people have experienced can lead to “white coat” hypertension which refers to blood pressure that is artificially high due to the stress of going to the doctor’s office. If the person had to fight to exercise their right of informed consent/refusal for the weigh-in (or if they agreed to a weigh-in and were subsequently fat-shamed) that can also elevate blood pressure (and, of course, that’s on top of things like being worried that they have a health issue and/or being in pain.)
Then there is the other side of this, where a fat person has a blood pressure in the '“normal” range and the healthcare practitioner expresses disbelief and/or takes the patient’s blood pressure repeatedly. While there is no shame in having “high” blood pressure, and no moral victory in having “normal” blood pressure, this too is weight stigma. It is essential that healthcare practitioners practice medicine and not stereotypes.
If you are a fat patient, you should not have to fight to get correct blood pressure using a properly-sized cuff, but you might find yourself in that situation.
The American Heart Association recommended sizes are:
Arm Circumference Cuff Size
22 to 26 cm 12 × 22 cm (small adult)
27 to 34 cm 16 × 30 cm (adult)
35 to 44 cm 16 × 36 cm (large adult)
45 to 52 cm 16 × 42 cm (adult thigh)
If it’s accessible to you, you can also get a wrist cuff for home. While it may not be quite as accurate it can at least give you a baseline. If they use the machine and it’s high, you can ask to have your blood pressure taken manually. Finally, know that you are allowed to decline (and you can ask them to put in your chart that they failed to have the proper sized cuff for you.)
If you are a healthcare practitioner, please do everything you can to make sure you have properly-sized blood pressure cuffs and appropriate training, policies and practices for fat patients. If you manage other practitioners, make sure they are clear on how to choose a properly-sized cuff for patients of different sizes including thigh cuffs and conical cuffs. And make sure everyone knows the options, including taking BP on the forearm when necessary. This should be seamless for your fat patients, just as it is for your thin patients. Wherever you have any power or privilege within the practice, create a culture where it’s unacceptable to give fat patients unequal care.
In part two of this series, we’ll take a look at the options for weight-neutral blood pressure management.
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*Note on language: I use “fat” as a neutral descriptor as used by the fat activist community, I use “ob*se” and “overw*ight” to acknowledge that these are terms that were created to medicalize and pathologize fat bodies, with roots in racism and specifically anti-Blackness. Please read Sabrina Strings Fearing the Black Body – the Racial Origins of Fat Phobia and Da’Shaun Harrison Belly of the Beast: The Politics of Anti-Fatness as Anti-Blackness for more on this.
Note I don’t link to everything I discuss in this post because I don’t want to give traffic and clicks to dangerous media.
This cuff size thing is such a peeve… I was an EMT and a CNA for a few years in the 1990’s and cuff size was drilled into our heads. Also everywhere I worked always had a range of cuffs, including XL/thigh cuffs. I don’t know WHAT happened, but in the mid 00’s I stopped seeing these larger cuffs and as a patient, I’m looked at like I have 4 heads when I ask for the largest cuff, because they don’t have one any more. What happened??? What changed?? I don’t get it.
I hate that I’m constantly told I have “pre-hypertension” or “we should talk about medication” because they’re taking my BP with too small of a cuff (while asking me questions and not wanting to be quiet as the cuff inflates and deflates) after arguing about not getting weighed. Of COURSE it’s gonna be high.
I wonder how many fat folks with low BP also don’t get proper diagnosis because of incorrect cuffs too. Providers are shocked it’s not high but what would they do if they learned their fat patients were actually dangerously low?
I’ve tried a couple wrist cuffs and I haven’t found one that seems really consistent. I think there are some high end ones that look really reliable but wow they’re costly. (Hopefully they’ll come down in price.) I’ve still got a manual cuff from my EMT days (which fits large arms!) so I’ll compare that to the auto cuffs on my partner, and even the wrist cuff is only off by 10-15 points, which is still more accurate than what happens in a doctors office between the stress and a bad cuff.
Absolutely a nightmare! Even when I had lower weight, I have large upper arms. This is a 50 year battle for me, a fat elder. A cardiologist in Hawaii told me exactly what you described: for accurate blood pressure the patient should have time to sit and relax prior to the reading, good back support, legs uncrossed, the proper cuff size, arm supported at heart level, and no chitchat during the reading. That has only happened at that doc's office.
I've been asked to hold the cuff on, told a too-small cuff was fine when the person wanted to use tape to keep it shut, been tsk-tsk'd at because my bp was "sky high" while my arm and the cuff were wedged tightly between a gurney's rail and my body (apparently doesn't make a difference?!), and told that having my bp taken manually was "not possible." Given proper circumstances, healthy bp so the Good Doc suggested I buy a properly sized unit with XL arm cuff and track my bp myself so I'd have good data. May do that one day...after my enormous lottery win.
Thanks for making it clear this is lunacy. I'm so disappointed it persists! Nobody should have to seriously consider whether the benefit of seeking medical care is worth the stress of doing so....