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According to the National Institutes of Health, approximately one-third of adults are estimated to be obese and one-half are estimated to be overweight. Obesity, also referred to as bariatrics, is believed to affect more than 58 million people nationwide. It has become a major health concern among health care providers because of related conditions that can arise from being overweight. Some of these conditions include hypertension, cardiovascular disease, Type 2 diabetes as well as some cancers in both men and women.

ASBP Information

Growing Knowledge

With the expansion of Americans' waistlines, health care providers are attempting to expand on their knowledge, while keeping patients educated about the growing problem of obesity.

Obesity poses a major public health challenge.
Two reports found in the New England Journal of Medicine and JAMA are completely devoted to obesity. The reports indicate that obesity continues to increase rapidly in the United States. According to one report, the prevalence of obesity increased from 12 percent in 1991 to 17.9 percent in 1998. The increase was steady in all states and was not affected by age, gender, educational level or smoking status.

The first federal guidelines on the identification, evaluation and treatment of overweight and obese adults were released June 17, 1998, by the National Heart, Lung and Blood Institute (NHLBI) in cooperation with the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDKD). The guidelines are designed to help physicians in their care of bariatric patients.

Guidelines and Strategies for Safe Weight Loss

"Obesity poses a major public health challenge. The development of these guidelines was a pioneering achievement since they were first developed by the Institute using an evidence-based model and methodology," said NHLBI director Dr. Claude Lenfant.

The guideline's definition of overweight is based on research, which relates body mass index (BMI) to the risk of illness and death. BMI describes body weight relative to height and is strongly correlated with total body fat content in adults. According to the guidelines, a BMI of 30 is about 30 pounds overweight and is equivalent to 221 pounds in a 6-foot tall person. BMI numbers apply to both men and women. The guidelines also recommend that BMI be determined in all adults.

"The evidence is solid that the risk for various cardiovascular and other diseases rises significantly when someone's BMI is over 25, and that risk of death increases once the body mass index reaches and surpasses 30," said Dr. F. Xavier Pi Sunyer, chairman of the expert panel and director of the Obesity Research Center, St. Luke's Roosevelt Hospital Center in New York City.

Helpful Aids

Bariatrics has been receiving more attention in the health care arena due to the many conditions that can arise from being overweight. This means a profitable venture for home medical equipment (HME) providers who supply the many products obese patients require. Manufacturers should stay educated about the bariatric market because many patients require special equipment such as wheelchairs or support surfaces to relieve some of the pain and side effects associated with obesity. Also, bariatric patients can require special customization of existing products.

Sometimes obesity can cause difficulty performing daily tasks due to limited mobility or physical dependence. Strength, reliability and quality are necessary components when designing and manufacturing bariatric equipment. According to Michele Eberle of Wheelchairs of Kansas, Ellis, Kan., the most important considerations in manufacturing bariatric equipment are durability and strength of materials used. Eberle also suggests having equipment with varying weight limits so patients are able to find a product that suits their particular needs.

According to an article written by Susan Gallagher, RN, MSN, CETN, CNS for <I>Ostomy Wound Management<I>, a health care journal, certain equipment such as wheelchairs, walkers, commodes and lifts can aid health care providers when caring for bariatric patients because family members and clinicians are at risk for injury when caring for obese patients. Oversized wheelchairs and walkers with greater weight capacities and limitations than standard equipment are readily available from various home medical equipment providers.

Manufacturers should inform HME dealers what special needs or selling tools and suggestions are available to ensure bariatric patients understand the specifications, uses and functions of their products. "We also listen to our customers' wants and needs," said Eberle. Patients who are confident that products will hold their weight, while at the same time supporting them without fear of falling, will feel better about purchasing equipment.

According to Gallagher, hydraulic or pneumatic lifts often are considered a necessity in the home care setting because of the few individuals available to assist patients. It is important that HME dealers and providers offer sound education about various products so family members, patients and caregivers all understand the different components, features and functions to eliminate any problems in future use.

When deciding on what types of equipment to buy, Gallagher suggests that users should consider weight limits or capacity, width and electrical functions, not only for delivery and set up purposes, but also for transfer from room to room within the home.

Durable medical equipment is sometimes an important need for bariatric patients, however obese patients also tend to suffer from other conditions such as pressure ulcers or incontinence. Various support surfaces are available to help prevent pressure ulcers because they offer benefits such as rotating air, which provides pressure reduction due to repositioning of the pressure cells within the mattress, aiding in the elimination of sores.

Incontinence sometimes can be an issue with obese patients because they are unable to make it to the bathroom in time. "Use of an oversized commode located near the patient's bed may prevent this problem, while at the same time increasing independence and mobility," Gallagher said. Also available to aid with incontinence issues are several briefs and pads, designed to provide ample protection in the case of incontinent accidents.

It is important that HME dealers also consider that bariatric patients may have other related health conditions such as hypertension where blood pressure cuffs may be needed. Keeping a stock of larger sized products will eliminate problems for bariatric patients when searching for a medical product required for daily use. Being aware of the related conditions, and what products are required to aid in managing those conditions, will help HME dealers better serve bariatric clientele.

Increased Sensitivity

Some of the most important considerations that should be made when working with bariatric patients are issues of sensitivity. Bariatric patients may have difficulties moving about the home or even leaving the home for what many of us consider to be very simple, daily tasks. It is vital that HME

It is vital that HME dealers and manufacturers consider the sensitive nature of a patient who is obese or overweight and try to make that person as comfortable as possible while trying to find required or necessary equipment.
dealers and manufacturers consider the sensitive nature of a patient who is obese or overweight and try to make that person as comfortable as possible, while trying to find required or necessary equipment.

Obesity is, in fact, a medical condition and while in the past, society has chastised those who do not fall within healthy weight guidelines or who suffer from other health problems due to a weight condition, obesity is likely to be a growing problem that will not go away.

HME dealers and providers may consider having educational materials related to exercise and nutrition to offer bariatric patients. Offering support and sensitivity to patients who may already suffer psychologically and socially may be what bariatric patients need to search for solutions to their current medical needs, as well as obesity.

Health care providers and home medical equipment dealers have an opportunity to provide products for patients' medical needs, while at the same time making them aware of other medical conditions related to bariatrics and products that may aid in treating those conditions.

Supplying bariatric patients with medical equipment is a necessary function to aid in daily tasks and for support of various related conditions. Through education and sensitivity, manufacturers and HME dealers can capitalize on the bariatric market, while at the same time making bariatric patients' lives easier and more comfortable.

Case Study Interview

The American Society of Bariatric Physicians (ASBP) is a national professional medical specialty society of licensed physicians and osteopathy who offer specialized programs in the medical treatment of bariatrics and its associated conditions. Formed in 1950, ASBP has been instrumental in offering practical information that doctors can use in their bariatric practices and that members of the general public can use in locating a bariatric physician.

For physicians, ASBP offers an exciting series of continuing medical education programs, a peer-reviewed quarterly journal, The American Journal of Bariatric Medicine - The Bariatriciain, and a bio-monthly newsletter, News from ASBP.

For the public, ASBP has information on the growing problem of obesity in the United States, ways to lose weight and maintain a healthy weight and a way to reach member physicians for professional consultation in dealing with weight loss problems.

For recent developments in the field of obesity treatment and medical weight loss and news of ASBP activities, visit the News and Views section of the organization's Web site at or contact The American Society of Bariatric Physicians, 5600 S. Quebec Street, Suite 109A, Englewood, CO 80111.

Guidelines and Strategies for Safe Weight Loss

According to the federal guidelines on obesity, established in 1998, the following are recommended as strategies for encouraging weight loss.

  • Patients should engage in moderate physical activity, progressing to 30 minutes or more on most or preferable all days of the week.
  • Reducing dietary fat alone--without reducing calories--will not produce weight loss. Cutting back on dietary fat can help reduce calories and is heart healthy.
  • The initial goal of treatment should be to reduce body weight by about 10 percent from baseline, an amount that reduces obesity-related risk factors. With success, and if warranted, further weight loss can be attempted.
  • A reasonable time line for a 10 percent reduction in body weight is six months of treatment, with a weight loss of one to two pounds per week.
  • Weight maintenance should be a priority after the first six months of weight loss therapy.
  • Physicians should have their patients try lifestyle therapy for at least six months before embarking on physician-prescribed drug therapy. Weight loss drugs approved by the FDA for long-term use may be tried as part of a comprehensive weight loss program that includes dietary therapy and physical activity in carefully selected patients who have been unable to lose weight or maintain weight loss with conventional non-drug therapies. Drug therapy also may be used during the weight maintenance phase of treatment. However, drug safety and effectiveness beyond one year of total treatment have not been established.
  • Weight loss surgery is an option for carefully selected patients with clinically severe obesity with coexisting conditions when less invasive methods have failed, and the patient is at high risk for obesity-associated illness. Lifelong medical surveillance after surgery is a necessity.
  • Overweight and obese patients who do not wish to lose weight, or are otherwise not candidates for weight loss treatment, should be counseled on strategies to avoid further weight gain.
  • Age alone should not preclude weight loss treatment in older adults. A careful evaluation of potential risks and benefits in the individual patient should guide management.

Case Study Interview

As obesity continues to be a concern in the health care arena, many patients are turning to surgery to help with losing weight. This interview was conducted in the hopes of bringing our readers a personal experience in dealing with the issue of bariatrics. James Elisha, 38 years old, Dallas, Texas, agreed to be interviewed about a recent surgery he underwent to help him lose weight. Answers are provided in his own words.

1.What is the heaviest you have weighed?

At the time of my surgery,I weighed 626 pounds.

2. At what age did you begin to notice you were gaining more


I would say around age 10 to 13.

3. What types of health problems have you encountered...such as heart problems or hypertension, blood pressure, trouble breathing etc.?

I have no heart problems or blood pressure issues. I have joint pain in my knees and back and sometimes have sleeping and breathing problems.

4. What other types of social problems have you encountered....for example, trouble finding a job, flying on airplanes or traveling accommodations in general.

Jobs have been no problem for me because I have worked in the same place since I was 16 years old, but I think I would have a problem getting a job if I did not have this one. Flying has been bad. A year ago, I had to buy two tickets to Las Vegas because I could not fit in one seat, but this year, because of the surgery, I bought one and it made me feel really good.

5. How has your weight affected how you perceive people?

This is a hard one to answer-I think I am more outgoing in a crowd of people but if I get one-on-one, I am kind of shy, especially around women. Ninety percent of women would not give me the time of day, and I can't say that I blame them.

6. What suggestions have doctors given you to try and help you lose weight, such as nutritional programs, diet or exercise regiments?

Back in 1981, this doctor gave me pills which helped me lose weight but they became addicting and I had problems sleeping, so I quit taking them and then gained all the weight back. I have tried every diet under the sun and they did not work for me. This surgery was the last resort and I don't look back, because it was the best for me. Doctors told me I'd be dead before I was 40 if I didn't take it seriously and now I have a whole life to look forward to.

7. Which programs or activities have you tried and did any of them work? If yes, please describe what was the most beneficial and if not, try to

explain why they didn't work.

I guess I did not have any will power and I felt this surgery was right for me because I have no choice but to eat less. If I eat too much or too quickly it all comes back up. I am planning on going to the gym to work out because I have not been able to do so in the past, and I think it will only help me lose weight faster.

8. What did you finally try?

Stomach staples was what I finally decided to settle on. For years, I played like I was happy with myself when all I was doing was lying to myself about my weight problem and avoiding the situation. I was unhappy for a lot of years?people who tell themselves they don't have a weight problem are only lying to themselves and making the problem worse. Sometimes I think it's sad that I am 38 years old, single and I have no kids-that's not right. I should be living my life to the fullest.

9. Has this worked for you? What did you weigh when you started and what do you weigh now?

This is the biggest step I have taken. I have lost 170 pounds in about 7 months so now I weight around 450 pounds.

10. What types of changes (eating/exercise) have you had to do since you had the surgery?

I've had to make a lot of adjustments. I never knew how tough it would be. The fist six weeks, I only had liquids and the second six weeks consisted of chopped up food, and it was really difficult to go almost 12 weeks without eating whole foods. It's been difficult because different foods cause different reactions. It's sometimes hard to digest red meats, and it was really hard breaking the habit of eating fast food all the time. My doctor said I do need to start exercising and that's why I plan on joining the gym.

11. How do you feel now that you have lost some weight?

I have not felt better in years. I feel like I got another chance at life. My knees do not hurt as much although I still have some back problems. Breathing is easier and I sleep better. I just really can't put it all into words.

12. What is your ultimate weight goal?

I would love to weigh around 250 pounds but anything under 300 pounds would be great.

13. Does your doctor say you will gain the weight back? What types of activities does he have planned for you to help speed up the weight loss process and to keep the weight off?

The doctor told me I was losing the weight a lot faster than they thought. Keeping the weight off won't be as difficult because with the staples, it is difficult to overeat.

14. In your own words, tell me how your life has been altered by the weight gain and the weight loss?

My weight has altered my lifestyle more than I could have imagined. I think about all the things I have missed out on, like prom night because nobody wanted to go with me. I feel like I should already have children and a wife with grandkids to follow. I sometimes felt some of my closest friends did not want to be seen with me. I have been lonely for a lot of years and even thought it is my entire fault, I refused to be pitied. I feel so much better since my weight loss. I just bought a new pair of pants today and it felt so good to have them eight inches smaller. I also bought a shirt from a normal store for the first time in 15 years. I feel it's a bit of a moral victory for myself. Sometimes I get bitter and think how great it will be to run into some of the people who treated me badly or differently because of my weight, but then again maybe I should thank those people because they are part of the reason I decided to make some changes.

This article originally appeared in the May 2001 issue of HME Business.

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