Adiposity: A Formidable Challenge in Acute and Critical Care

The word obesity originates from the Latin word obēsus (on account of eating), which focuses on behavior as the cause.³  Despite the origins of the word, physicians at the American Medical Association (AMA) 2013 Annual Meeting voted to acknowledge obesity as a disease.⁴  These AMA physicians reached a consensus that obesity is multifactorial and not solely caused by poor lifestyle choices such as overeating or lack of physical activity.⁵  Following the 2013 AMA meeting, there has been further debate and scientific interest among researchers, pharmaceutical companies, and the medical community, resulting in clinicians better understanding the various causes of obesity and how to diagnose and manage this disease early.

Labeling obesity as a treatable disease is a paradigm shift for many health care providers and patients. However, whereas many in the medical community applaud recognizing obesity as a disease, others feel that labeling obesity as a disease may be inaccurate; they believe that obesity is a factor contributing to some of the leading causes of preventable death such as stroke and diabetes.^5,6  Both perspectives have merit, and with the acknowledgment by AMA’s physicians that obesity is a disease, hopefully a psychological benefit to patients living with obesity will follow.

This fundamental change in thinking may lead to earlier diagnosis by clinicians and safer treatment options for patients with adiposity.⁴  Bariatric patients often feel guilty about their inability to lose weight and blame their physical appearance on their own shortcomings. Understanding that their obesity is a disease may help patients overcome some guilt and shame, making them more receptive to treatment options.

Although evidence suggests that obesity is caused by a variety of genetic, environmental, socioeconomic, hormonal, and medicinal factors,⁴  many clinicians when assessing a patient with adiposity attribute obesity to the patient’s lack of willpower over food.^1,2  Moreover, many health care organizations’ financial constraints result in elimination or reduction of bariatric education and training programs for nurses in the acute and critical care setting.⁷  Preconceived beliefs coupled with gaps in bariatric education and training for clinicians make it difficult for people with adiposity to understand and manage their disease in the primary and acute care settings.²  Thus, we as health care providers need to evaluate our current systems, reflect on our own biases, work to change societal attitudes, and improve our structures and processes to ensure that all health care team members can provide evidence-based care interventions and dignified, respectful care for our patients with adiposity.

In the United States, the fast-growing numbers of patients with adiposity means that there may be more bariatric patients admitted to intensive care units (ICUs) and progressive care units. Care of bariatric patients presents many challenges to ICU care teams that may affect patients’ safety.⁸  In the ICU, critically ill patients with adiposity require intricate and detailed monitoring that is resource, time, and labor intensive,⁸  and much of this care may not be adequately reflected in hospitals’ patient acuity systems. Health care teams may not have adequate staff (eg, lift teams) to optimally care for these patients. In turn, inadequate staffing and lack of resources can result in treatment delays or selective avoidance of care and basic nursing tasks (eg, skin assessment, bathing, turning, wound management, mobilization) until enough staff are available to assist with the care.^8,9 

A qualitative study by Shea and Gagnon¹⁰  confirms the existence of treatment delays for patients living with obesity and documented many of the perceptions experienced by nurses in an ICU environment. This study, which used the othering framework (a process that describes how we engage with others whom we perceive as different from ourselves),¹¹  explores nurses’ experiences caring for patients with obesity and how these experiences affect care delivery. Four themes emerged from the study: (1) how the patients become others in the ICU, (2) exclusionary othering practices in the ICU (eg, witnessing instances of bias and an inability to provide care), (3) positive inclusionary practices in the ICU, and (4) resources affecting nurses’ experiences.¹⁰  Shea and Gagnon found the ICU environment to be a driver of othering and noted that the care of patients with obesity in the ICU is intertwined and complex.¹⁰  However, more research and ICU-specific studies relevant to clinical and nursing care are needed for this patient population.

Intensive care units are fast-paced arenas where routines are rigid, technological advances are abundant, and staffing and resources are scarce. Therefore, it may be difficult for ICU team members to imagine how the time-consuming and labor- and resource-intensive nursing care that bariatric patients need can be implemented in the same way that other patients receive care. Most facilities do not provide the same staffing and clinical practice guidelines for managing and caring for bariatric patients that they do for other patient populations.

To provide equitable care for patients with adiposity while maintaining safety for patients and staff, organization need to reevaluate their current care delivery systems. Health care facilities must develop bariatric policies and procedures and create staff guidelines based on acuity systems that are reflective of actual nursing time spent with this vulnerable population. All team members, including patients, must be involved in the decision-making process. By examining current systems, advancing our understanding of obesity as a disease, and adopting recommendations based on evidence, we may be able to improve the current work environments and the care disparities affecting the bariatric patient population.

The 4 articles in this symposium are written by certified bariatric advanced practice and critical care nurses. In the first article, Rachel Smigelski-Theiss and colleagues review psychosocial and physiological outcomes (eg, depression) of bariatric patients that result from obesity, childhood experiences, and structural designs of the physical environment. The authors examine evidence of weight bias and stigmatization in the health care setting of this patient population. The second article by Aura Petcu and the third article by Susan Gallagher and Cheryl Holsworth examine the overall care challenges experienced by clinicians and patients during bariatric surgical procedures such as gastric sleeve gastrectomy. These 2 articles discuss the more complex ICU nursing care required in the management of bariatric patients in acute and critical care including key monitoring of potential complications. In the final article of the symposium, Heather Roff and Colette Jappy examine adiposity and how the neuroendocrine hormones play a role in regulating obesity and energy balance.

We hope this symposium stimulates dialogue and spurs future research to help clinicians better understand and improve the health care systems and processes to better care for the bariatric patient population. We hope you enjoy reading the articles and find the clinical applications relevant to your practice setting.