Study Looks at Higher-Weight People and Nursing Practice

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Today I want to dig into a scoping review that looks at nursing care for the highest-weight people - The Nursing Care of People with Class III Ob*sity* in an Acute Care Setting: A Scoping Review by Ewens et al. 2020

I’ll start with some introductory info:

“Class III ob*sity” refers to a deeply problematic system that classifies people based on Body Mass Index (BMI.) Class III is the highest classification. It is unique in that while other BMI categories, while completely useless, are at least precise in that they encompass around 5 BMI points each, “Class III” is literally anyone with a BMI of 40 or greater which is not an ethical or scientific way to categorize people, which I go into this in detail here.

I’ll also point out that this study utilizes “person-first language” which is being pushed by the weight loss industry and rejected by weight-neutral health community and fat activist community.

The goal of a scoping review in general is to present an overview of the literature that exists on a particular topic – they can identify knowledge gaps, clarify concepts, and be a precursor to systematic review.

The goal of this scoping review was “to synthesize the evidence on the nursing care of Class III ob*se patients in acute care settings.”

Their conclusion is not surprising, but it is important:

A paucity of high-quality evidence informs the nursing care of people with Class III ob*sity in acute care. Access to appropriate equipment dominated the findings of this review. Adequate provision of equipment and education on its use are required. Education to promote engagement with patients, adapting clinical practice and promotion of self-care could improve care and outcomes.

In truth, there is a severe lack of high-quality evidence to inform any healthcare for higher-weight people and even these few studies (including those that claim to explicitly study weight stigma,) either specifically exclude the highest-weight people, or don’t make any differentiation between sizes. This is a serious issue when it comes to healthcare because the higher someone’s weight, the more likely they will be to face discrimination in accommodation in everything from chairs, gowns, and blood pressure cuffs to surgical tools and hospital beds and more due to structural weight stigma.

The review states:

To ensure clinical staff deliver care based on best available evidence, it is essential to develop and make widely available, policies and procedures that focus on lifting protocols, lift teams, appropriate equipment and algorithms to promote safety and dignity.

The review found that

The majority of studies identified that acute care settings were not designed to care for patients with Class III ob*sity and accommodate their care needs, particularly in relation to dedicated equipment. Most facilities were retrofitted and not fit for purpose to accommodate patients with Class III ob*sity.

Equipment to accommodate higher-weight people exists, but often it is not purchased, or not purchased in sufficient quantities, leading to patient harm. Worse, often that harm is blamed on patients’ bodies either directly by claiming that the patient is too big, rather than at least acknowledging that the equipment is too small, or, less directly, when research of patient outcomes blames poor outcomes on higher-weight patients’ body size rather than on the discrimination and lack of accommodation they experienced in healthcare settings.

In a simple example, if an office only buys one of the largest blood pressure cuffs, rather than finding it for each patient who needs it, the person who is charged with taking blood pressure (who may be under time pressure) is more likely to just use a cuff that is too small, giving the patient a reading that is too high. The stakes get much higher when the equipment involved is used to lift and move the patient. Practitioners can also be harmed by a lack of equipment if they don’t have what they need to properly care for higher-weight patients. In my experience as both a “class III ob*se” person and someone who has advocated for other people in this (deeply flawed) category, often the lack of accommodation is compounded by practitioners who blame fat patients for existing (either saying it to us directly, doing a lot of sighing and eye-rolling, and/or talking about us (but not to us) in front of us,) or coming from a perspective of “how dare this patient expect to have a bed/chair/blood pressure cuff/MRI that accommodates them,” rather than being horrified that they don’t have what they need to properly care for patients and seeing themselves and their fat patients as being on the same team, fighting against the lack of accommodation.

Lack of training is definitely an issue that isn’t necessarily the healthcare provider’s fault, but ultimately becomes the patient’s problem. I was advocating for a superfat (her preferred descriptor) patient at the hospital and they didn’t have a bed that was rated for her weight. They were able to rent a bed (with the patient sitting in pain on a hard plastic chair for over two hours hours until it got there.) Unfortunately, when it got there nobody knew how to use the bed and multiple calls had to be made to get basic information. By that time the patient was in significant, lasting pain and it was absolutely unnecessary. Healthcare facilities are fully aware that fat people exist, so for those who are in charge of management/procurement to wait until a fat patient is there and in need of care to start just considering how to acquire even the most basic things (like a hospital bed in a hospital) is inexcusable (yes, even if it’s couched as “budget considerations”) If the only way for a hospital to maintain their budget is to utterly fail to provide adequate care to some of their patients, then they should re-think their budget, perhaps starting with their executive’s compensation model.

It is recommended that a consistent approach to terminology should be adopted such as those defined by the WHO which are widely accessible. Consistency in the application of terminology could make a significant impact on patient care.

I would point out that this is an opportunity to decrease stigma by choosing terms that are preferred by those seeking fat liberation, that don’t pathologize body size, with a reminder that much of the World Health Organization’s work around fat bodies has been led by people and organizations who profit from the weight loss paradigm, including and especially the pharmaceutical industry.

Wound management in patients with ob*sity is further complicated by a lack of an evidence base, which has been identified as a particular issue.

This is something that comes up a lot in my work. Often, the lack of information about best practices for wound care for higher-weight patients (or the idea that these patients might need more/more expensive care,) is used as an excuse to deny care to those patients. Here again, this often seems to come from a place of weight stigma in the form of the belief that, rather than getting better at caring for higher-weight patients, higher-weight patients should be forced to lose weight in order to deserve/receive ethical, evidence-based care.

So, while still steeped in weight stigma in places, this is generally decent information, and I absolutely agree that we need more research (so much so, that I’m conducting a study with Dr. Lesleigh Owen about weight stigma and iatrogenic harm in the highest-weight patients!)

Unfortunately, when it comes to the review’s abstract - typically the first thing that people will see, we see how deep the weight stigma runs, even among researchers whose stated goal is to, ultimately, improve care for the highest-weight people:

Patients with Class III ob*sity pose unique challenges to health care staff and organisations. Care requirements of this population are unique and require specialised equipment and knowledge to meet these needs, maintain the quality of care, as well as the safety of patients and staff.

The way that they blame the patients here is a perfect example of weight stigma. The patients don’t pose a challenge to providers and organizations. The failure to have proper equipment and adequate research and training poses a challenge first and foremost to the patients (who face the most harm,) and also to providers. The equipment and knowledge needed is only “specialized” because these patients have, for so long, been ignored in research, equipment and medical practice.

The first step to ending the unequal and subpar care of higher-weight patients is to stop blaming the patients for existing, to stop consider the things that higher weight people need (most of them things that thin patients get automatically) to be “specialized,” and to create healthcare environments where everyone views patients of all sizes as worthy and deserving of care, and views the lack of accommodation for patients, including those of the highest weights, as a completely unacceptable problem to be solved.

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More research and resources:
https://haeshealthsheets.com/resources/

*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.