Improving Medical Care for Larger-Sized Patients:
Suggestions for Health Care Professionals

“We cannot tell the state of one’s health by the size of one’s body.” 
—Dr Dianne Budd, Endocrinologist, UCSF Obstetrics & Gynecology

Thank you for taking the time to read this guide sheet about how to provide better medical care to our larger-sized membership.  This guide sheet will suggest ways you can make improvements in your practice to help this group of patients feel welcomed and well treated.

Larger-sized patients often feel unwelcome in medical settings, where they encounter negative attitudes, discriminatory behavior and a challenging physical environment. These negative experiences explain, at least in part, why larger patients are more likely to delay seeking clinical breast exams, gynecological exams and Pap smears— delays which account for some of the increased health risks of obesity.  If this group, which represents an ever-increasing portion of our primary care patients, is to receive adequate preventive services and adequate diagnosis and treatment of co-morbid conditions, we must change the way we care for them.

Heavy people frequently feel shame about their size. It’s important that health care settings be safe havens where patients feel free to ask for assistance not only with weight management but a full spectrum of wellness issues. Areas where many heavy patients have reported feeling stigmatized range from well-meaning but hurtful discussions of weight loss to the difficulty of finding an appropriate-sized chair in the waiting room. 

“Weight Bias is common in health care settings. Rudd Center research studies have shown that health care professionals are among the most common sources of bias. This includes physicians, nurses, psychologists, dietitians, medical students, and even professionals who specialize in obesity. Some professionals within these groups perceive overweight patients as unintelligent, unsuccessful, weak-willed, unpleasant, overindulgent, and lazy. The frustration that clinicians feel when trying to help patients lose weight may contribute to this bias. Rather than acknowledging the limited effectiveness of current weight loss treatments, health care professionals tend to blame their patients for non-compliance and lack of self-discipline.

“Weight bias in health care settings can cause serious harm. Research has demonstrated that heavier patients are more likely to avoid, cancel, or delay important preventive services. When asked why, obese patients attribute these decisions to disrespectful treatment and negative attitudes from providers, unsolicited advice to lose weight, embarrassment about being weighed, and bad experiences with medical equipment that is too small for them. The percentage of patients who reported these barriers increased with body mass index.”
—From Preventing Weight Bias—Helping without harming in clinical practice. (http://yaleruddcenter.org/resources/bias_toolkit/index.html)

Kaiser Permanente is working to address these issues through a variety of means, though they still have a long way to go.

Our National Weight Management Initiative states:
“Explicit education about weight bias and strategies to prevent weight bias has been a backbone of our national and regional weight management training for clinicians. . . Kaiser staff have been actively involved with national facility design staff to ensure that architecture, purchased furniture, and medical equipment support a welcoming environment and quality of care for persons of all sizes. They have as their goal to ‘develop both sensitive and innovative ways to improve care and services for obese persons.’”

Weight bias in medical care settings and among health professionals is a major concern.  With more than 65 percent of adults in this country officially overweight and nearly 33 percent obese, weight bias has direct consequences for health in the United States. 

These statistics may surprise you:

In a survey of 2,449 overweight and obese women:
69% experienced bias from doctors
52% experienced recurring incidents of bias

In a study of 400 doctors:
~ 1 out of 3 listed obesity as a condition to which they respond negatively, ranked behind only drug addiction, alcoholism, and mental illness.
~ Obesity was associated with noncompliance, hostility, dishonesty, and poor hygiene.
~ Self-report studies show that doctors view obese patients as lazy, lacking in self-control, noncompliant, unintelligent, weak-willed, and dishonest.
~ Psychologists ascribe more pathology, more negative and severe symptoms, and worse prognosis to obese patients compared to thinner patients presenting identical psychological profiles.

Doctors seeing larger-sized patients:
~ Spend less time with the patient
~ Engage in less discussion
~ Show reluctance to perform preventive health screenings (i.e., pelvic exams, cancer screenings, mammograms)
~ Do less intervention

In a study of nurses:
31% said they would prefer not to care for obese patients.
24% agreed that obese patients “repulsed them.”
12% said they would prefer not to touch obese patients.

Larger patients need practitioners who know that every problem is not due to their weight.  Although physical examination may be more difficult in large patients, the disproportionate risk for some illnesses that are amenable to early detection increases the priority for preventive evaluations and for sensitively addressing concerns with patients who may initially be reluctant to undergo appropriate testing. Recommended preventive evaluations, including Pap smear, physician breast examination and mammography in women, prostate examination in men and stool testing for occult blood can be performed in patients of all sizes. Physicians can encourage improvements in healthy behaviors, regardless of the patient’s desire for, or success with, weight loss treatment. 

Adapting the Office for Large-Sized Patients: Access to Care

To provide the best possible medical care for plus-sized patients, create an office environment that is accessible and comfortable for them. This includes educating staff about being respectful to patients regardless of body weight or size, and having appropriate equipment and supplies available.  Simple accommodations, such as providing large-sized examination gowns and armless chairs, as well as weighing patients in a private area, may make the medical setting more accessible and more comfortable for our larger patients. 

Sensitivity in word choice will also be helpful. Patients may respond extremely negatively to use of the term obesity, but be more amenable to discussion of their difficulties with weight or being overweight.  (NOTE: in performing a Pap Test, discussion of weight need not come up.)

Checklist for Assessing the Office
Exam Room
~ Stepstool with handle for exam table access
~ Large size gowns
~ Large and extra large adult and thigh blood pressure cups
~ Long vaginal specula
~ Wide examination tables, bolted to the floor
~ Hydraulic tilt tables, if possible
~ Sturdy armless chairs

Waiting Room
~ Armless chairs that can support more than 300 pounds
~ Firm sofas that can support more than 300 pounds
~ Ensure 6–8 inches of space between chairs
~ Weight-sensitive reading materials
~ Doors and hallways accommodate large size wheelchairs, walkers, scooters
~ Bathrooms with split lavatory seat with handled urine specimen collector
~ Bathrooms with properly mounted grab bars and floor-mounted toilets

Scale
~ Wide-based scale that measures more than 350 pounds
~ Meets established accuracy requirements
~ Accessible for patients with disabilities
~ Situated in a physical location that offers privacy and confidentiality
~ Wide platform with handles for support during weighing

These suggestions were adapted from: Kushner RF. Roadmaps for Clinical Practice: Case Studies in Disease Prevention and Health Promotion–Assessment and Management of Adult Obesity: A Primer for Physicians. Booklet 9: Setting up the Office Environment. Chicago, Ill: American Medical Association; 2003.
 
Improving your office space and procedures

A practice’s physical environment and office procedures affect the quality of the larger patient’s experience in the primary care setting. To improve in these areas, begin with a simple evaluation of your practice in terms of its user-friendliness to heavy patients. Walk through your practice, following the path a patient would take, and consider what changes you might make to both the physical environment and office procedures to enhance comfort and safety. It can be helpful to ask several of your larger patients about physical aspects of the office and office procedures they find particularly helpful or burdensome because of their weight. You should also take into account the Americans with Disabilities Act (ADA) Title III to ensure your practice is complying with disability rights laws. (You can find an ADA guide from the U.S. Department of Justice at http://www.usdoj.gov/ crt/ada/cguide.htm.)

When assessing whether your office’s physical setup is welcoming and comfortable for larger patients, be comprehensive. Sensitivity to the needs of heavy patients may require attention to parking, office entry, furniture, medical equipment, supplies and office reading material. You may even need to work with specialized vendors to address the many needs of this patient population. The initial cost of upgrading your office may be offset by larger dividends in the long run as your office becomes more accommodating to a broader range of clientele.

Rethink your office procedures: larger-size patients may find it burdensome to sit down and stand up repeatedly, so any change you can make to minimize the number of “stops” in a visit can decrease their burden.  At the same time, it is important to make comfortable seating available at any point where a delay may occur, such as at the check-out desk. Also, many people - particularly those who are heavy - are very sensitive about being weighed. Unless weight monitoring is medically indicated (e.g., for infants, children, pregnant women, individuals on weight-loss programs or those who have medical problems such as congestive heart failure for which weight monitoring is essential), consider giving your patients the choice to be weighed or not. And always measure their weight in private.

Improving the interaction

Sensitive office procedures and physical comforts will go a long way toward creating a welcoming environment for plus-sized patients. But above all, regardless of their weight, patients need to feel cared for by their physicians and the rest of the medical team. To accomplish this in your practice, you need to address knowledge and skill deficits as well as negative attitudes and behaviors that may exist among your colleagues and office staff.

Knowledge and skills. Physicians and their medical teams must understand the special needs and concerns of heavy patients and be prepared to deal with them in the clinical setting. To make their visits easier, treat your larger patients with the same consideration and respect you would show to any other patient. Encourage heavy female patients to get pelvic examinations as often as any other female patient. Be friendly and open, but careful with humor or any comments that could be taken as offensive. Have the correct instruments, such as a large speculum and large blood pressure cuff, easily accessible in the examination room. Take the time to do a thorough clinical breast examination and to teach the patient how to do a self-examination, just as you would do for an average-sized patient. During the pelvic examination, be gentle and do not rush. Remember how embarrassed or vulnerable any patient can feel in this situation, yet take the time to perform a complete examination. It may be necessary to raise the patient’s legs and flex the hip more in order to get a good view of the cervix, so make sure the nurse or medical assistant is prepared to assist the patient if necessary. And finally, avoid any display of frustration or distaste when doing a difficult examination. (A similarly sensitive approach needs to be taken during rectal and prostate examinations.)

Given the cultural pressure to be thin, many people of size feel considerable shame and blame themselves for being overweight. They are likely to be quite aware of the health implications of obesity and to have dieted, lost and regained weight numerous times. They often know more about programs to address weight than their health care providers may know. Given the demonstrated difficulty in taking off weight and maintaining weight loss and the dangers of yo-yo dieting, it is often judicious for physicians to avoid aggressively addressing the need for larger patients to lose weight, especially early in the doctor-patient relationship. It may be more useful to focus first on very modest goals, such as avoiding further weight gain or increasing physical activity, and to address other health issues, such as the need for preventive screening or the treatment of co-morbid conditions.

This model of care asks physicians and their staffs to simply focus on the person, not the obesity.

—From the article: Toward Sensitive Treatment of Obese Patients - Compassionate care will help them even if they never lose a pound.  By Syed M. Ahmed, MD, MPH, DrPH, Jeanne Parr Lemkau, PhD, and Sandra Lee Birt, Jan. 1, 2002, American Family Physician (http://www.aafp.org/fpm/20020100/25towa.html).

Help people of all sizes to thrive.  Please keep looking for ways to create a welcoming environment for this ‘sizeable’ and deserving part of our membership.
Feel free to contact us for additional resources and suggestions.

Sincerely,
Alice Ansfield, Research Assistant to Dr Nancy Gordon
Kaiser Permanente Division of Research, Oakland CA
510-891-3513
.(JavaScript must be enabled to view this email address)

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Resources and References: Content partially adapted from Yale University’s Rudd Center for Food Policy and Obesity (yaleruddcenter.org/what_we_do.aspx?id=204), the National Association to Advance Fat Acceptance (NAAFA: naafa.org), the American Academy of Family Physicians: Medical Care for Obese Patients: Advice for Health Care Professionals - National Task Force on the Prevention and Treatment of Obesity (© Jan 1, 2002), and from the Council on Size and Weight Discrimination.

See also: National Association to Advance Fat Acceptance: Guidelines for health care providers in dealing with fat patients, and Health and weight at Kaiser Permanente: practice recommendations, 1999. Oakland, Calif., Kaiser Permanente Regional Health Education. Pamphlet, and Radiance: The magazine for large women - celebrating body acceptance since 1984.