Among Giants
Courageous Stories of Those Who Are
Obese and Those Who Care for Them
SMASHWORDS EDITION
* * * * *
PUBLISHED BY:
Michael Dionne, PT on Smashwords
Among Giants: Courageous Stories of Those Who Are Obese and Those Who Care for Them. Copyright © 2006 by Michael A. Dionne, PT
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Michael Dionne, PT
Choice Physical Therapy, Inc.
There is no greater gift than to assist another in achieving success over adversity.
Michael Dionne, PT
Among Giants may be purchased for educational, business, or sales promotional use. For information, contact:
mdionne@bariatricrehab.com or call (770) 532-4327.
Library of Congress Cataloging-in-Publication Data
Dionne, Michael.
Among Giants: Courageous stories of those who are obese and those who care for them / Michael A. Dionne.—1st ed.
Includes sources and resources.
ISBN 978-1-4303-0945-1
Diet/Health. I. Title
Acknowledgments
I would like to thank the many people in health care, in hospitals, in nursing homes, and elsewhere, with whom I have worked as a physical therapist and consulting caregiver, for the opportunity to learn about the challenges and triumphs of those of significant size. I would especially like to thank those courageous souls of size whose amazing qualities and positive spirit teach us all so much.
I would like to thank my colleagues who have inspired me in my career and life. I am thinking particularly of the members of the Wisconsin Judo Association, Marquette University Staff and Associate Professor of Physical Therapy at Marquette University, Dennis C. Sobush, who always encouraged the exercise of creativity, even in the most complicated of clinical scenarios.
I would also like to express my appreciation to my eight year old daughter, Katie Rose, who accepts other children readily and who reminds me why we need sensitivity to interact positively where there is diversity.
I must include a very special thank you for my mother, Margaret Rose Dionne, who is a retired nurse, and my sister Peggy Ann Dionne, RN, for whom I am thankful for their love and encouragement. Lastly, I would like to thank my wife who has, through her intelligence and patience, encouraged my ideas and approaches; affectionately special thanks Nancy Sturtevant.
Additional thanks for their assistance in creating the fictional character maps, Mark Graham and our researcher John Nance of Mark Graham Communications. I would strongly recommend the great people of WordTechs Writing Services for their fine assistance in bringing the final promise of this book to reality.
Finally, I'd like to thank Audie Murrell for the outstanding illustrations included in this work.
Foreword
Among Giants is a series of fictional stories created to articulate life lessons to a world often blinded by negative views directed toward those of significant size. No real names, locations, or scenarios have been used. The stories have been created to express events that occur in any city in any country. I remind the reader to respect that there are striking similarities experienced by persons of size in actual falls and injury-related scenarios and to respect that the depictions in this volume are fictional. The hope for this book is to expand the current view of those of size and reveal the true diversity that exists within the population of size. By identifying the failings of health care providers and humanizing those within the population of size, I hope to improve their overall care and management. Never before has a complex health and social issue been so relevant for such a unique patient population. The subject should be a front-page story.
My purpose is to articulate the challenges and accomplishments of both those of significant size and their health care providers. The goal is to provide authoritative information concerning many aspects of bariatric rehabilitation and well-being. Among Giants addresses the primary considerations in accommodating obese patients, getting such patients mobile, and providing emergency medical procedures. It is presented in understandable (but not oversimplified) language. For the lay reader, Among Giants defines complicated medical terms clearly and concisely. Anyone can learn to recognize, respect, and better understand the problems faced daily by people of size. The book will help families and friends to work in conjunction with nurses and doctors in providing the best care.
Each chapter employs a fictional character to express the physical challenges unique to those of size. The text includes Dionne’s Bariatric Body Types (first written in 1992) and an explanation of the Performance Triad. The chapters take each fictional character through the complexities of the health care system and dynamics of care that present physiological and social implications in a thoughtful and meaningful presentation. At the conclusion of each chapter, there is a “lessons learned” segment that provides discussion specific to each case.
Historically, intervention for the patient of size taxed the ingenuity of nurses and therapists. The caregivers had to solve problems through innovation and fabrication, as they did to manage the traumas of wars or epidemic outbreaks such as polio. Among Giants is a source of current information on morbid obesity, with a review of problem areas in a readable, fictional, case-study format. I provide a unique view of diversity within the population of size by explaining a new system of body type classification that describes acuity of treatment phase in great depth with practical advice for those who are new to the field. For the general interest reader, it addresses the specific psychosocial issues that compromise wellness in patients of size and the multiple disorders that can affect intervention.
Anyone who knows a person of size, works with those of size, or intends to become involved in the health care industry will benefit from this incredible resource. The people they care for will thrive as well. Among Giants also speaks directly to our American culture, a culture rapidly moving toward a population growing in size. It discusses what the individual can do to elevate their heart rate and calm their mind, thereby elevating our culture’s metabolic set point toward greater activity and greater health.
I have devoted over sixteen years to bettering the care of the population of size. In the late 1980s, I was asked to help a fellow physical therapist in the evaluation of his first patient of very significant size: a man of over 1,000 pounds with the cognitive capacity of a four-year-old. That was the beginning of a journey that would take me all over the United States, Canada, and Europe, to redefine safe management techniques for people of size, culminating in the formation of Choice Physical Therapy, Inc., founded in 1992. I know bariatrics like no one else, and today, I travel internationally to assist healthcare facilities get patients of all sizes to become mobile again. I revolutionized therapeutic grips and the use of mechanical mobilization to meet the needs of the person of size. I have devoted my knowledge and experience to this unique population and am dedicated to helping the healthcare community improve their quality of service to persons of size while creating a safer work environment.
Chapter 1. The Consequences of Size
As a physical therapist, I have worked with many people who weigh up to 1,000 pounds. In each case, I have had to modify techniques to successfully mobilize those of significant size that are dependent. In the beginning, the challenges surprised me, and the patients often impressed me. Many of the stereotypes that I had anticipated quickly melted away in the motivation of the moment and the heroic battle for independence many of these individuals waged.
Now, almost twenty years later, I am convinced that the typical medical view of the diversity within the bariatric population is far too limited. In fact, I find that I very rarely think in the typical medical jargon of bariatrics or obesity in my work; and, when I do, it is specific to equipment. I rarely use the word “obesity." I usually refer to a patient who weighs up to 500 pounds as a “person of size." For those between 500 pounds and 1,000 pounds, I use the term “person of significant size." For me, the phrases have evolved since early 1991 from contact with actual patients. These patients simply did not feel comfortable with the traditional jargon. Many persons of size have been subjected to a cultural stigma and negative view of obesity. The new wording seems to work well and is meant to be respectful. Some patients feel uncomfortable with being classified as “bariatric,” “fat,” “big,” or “obese,” and with the names of related equipment, such as “Big Boy Beds." Therefore, it worked out that reference to size and significant size became the most uncontroversial means to discuss and minimize the risk of offence associated with typical jargon. This helps establish a positive patient rapport.
I believe many more people of size fight for independence than the media portrays. The daily news is dominated by the negative health aspects of size and rarely portrays a heroic, personal story unless it is related to surgical intervention or medicine. We need to bring the individual patients back into the focus.
Once, I attended a conference where a presenter made reference to the “Bariatric Personality,” and presented classes based upon the management of this categorization. This approach is an oversimplification of a group and does a huge disservice to individuals within the population of size. To generalize the entire population of size as being typified by anxiety and depression is an inaccurate and stereotypical depiction. It would be a great deal more accurate to identify that anxiety, depression and inappropriate coping mechanisms dominate where people are weak relative to body mass and are found to be common for those individuals who are dealing with multiple medical complications, rather than to suggest these psychological issues are a characteristic present in the entire population of size. There are at least as many people of size who are independent, fully-functional, well-adjusted, with very affectionate relationships, and who do not exhibit the negative characteristics too often attributed to size.
Clinicians who work with the population of significant size quickly learn that many of these individuals have been business owners or hold advanced degrees and often have above average intelligence. I am seeking to avoid a care environment that trivializes the individual and generalizes the health care intervention.
When a health care worker treats a patient known to have anxiety or depression in the average size population, the caregiver should finish his work professionally and leave the room without dwelling on it. The visit should remain confidential. When an untrained health care worker walks into a room and is presented with a patient of 850 pounds who happens to have the same level of anxiety or depression, the caregiver rarely behaves professionally. Too often, upon initial contact, the caregiver’s gaze is directed to the patient’s spread. As a result, the caregiver will bury his face into his clipboard feeling at a loss as to what to do and will even forget to introduce himself to the patient. Most patients look directly at the eyes of the caregiver as the caregiver enters the patient’s room. The caregiver’s misguided glance and awkward indecisiveness may be perceived by the patient as judgment. This is the vital moment where any chance at developing a rapport is lost, and communication becomes forever compromised. This negative first impression may perpetuate itself as it is reinforced by other insensitive caregivers for years to come. Too often, the untrained caregiver struggles to complete the task and leaves the room frustrated and inadequate. The untrained caregiver is not physically adequate to mobilize or care for the patient. As he walks down the hall seeking help from co-workers, the stereotypes walk with them. “Did you see that patient in room 232? What am I going to do?" The caregiver broadcasts his frustration and inadequacy at the nurse’s station. The nurse’s station is an open public forum where any bystander can get an earful of unprofessional demeanor.
“This patient weighs 850 pounds, and I’m 130 pounds. How do they expect me to get this patient up four times a day? Can you believe this order, who do they think I am, Superman or something? What the heck am I going to do?”
Many lawsuits have derived from far less harmful public displays of confidential patient information. When caregivers get sloppy with confidentiality, many negative consequences can occur. Beyond litigation, the media could get involved. I have performed charity visits and found staff members who have traveled across the medical campus just to sneak a look into the patient’s room. This was disrespectful conduct, a violation of patient privacy and a potential cause for a hostile environment for the patient. These problems can be prevented with training in patient confidentially.
Thankfully, with the development of new medical equipment and sensitivity programs, healthcare workers have become empowered to provide better care for patients of all sizes. The equipment gives us the physical adequacy to defeat the stereotype. When a caregiver has been trained in the correct use of bariatric equipment, the awkward moment of a misguided glance and overall inadequacy can be eliminated.
The Bariatric Triad refers to the minimal equipment required to safely manage the patient of size. It includes the starting surface, like a weight-rated bed, a lift and a target surface such as a wheelchair. (1) When the minimal equipment is combined with sensitivity training, a powerfully positive environment is created where miracles can happen. With training and equipment, the caregiver is empowered because they have a plan to offer to the patient. There is no excuse for pause and inadequacy where there is potential to act positively toward success.
Since 1992, I have performed as many as five sensitivity and safety programs in a single week and 150 programs in a single year. In one of our earlier programs, I recall talking to a group of about 200 nurses at a convention. We were on the topic of patient rapport when, for the first time, I thought to ask the audience: “How many of you have witnessed another professional use harsh or degrading language toward a particular patient?" Almost all the hands in the room went up. Then I said, “Wow! That says a lot. Is there anyone here who has never seen degrading language used toward a patient, because I want to work where you work!" No hands went up. We all had a laugh over that. It is a segment I continued to use in my talks, and the results are consistent -- nearly always 100% of respondents have witnessed another professional using harsh or degrading language toward a patient.
Obviously, healthcare workers are better than this test demonstrates; however, it does raise an interesting point, which the following story illustrates. I was working with a patient who was referred to therapy directly from the emergency room demonstrating a very significant self-care deficit. The patient had spent a number of weeks in a sleeping bag and did not come out for any reason, which resulted in terrible skin compromise. This client was transferred directly from the emergency room to the hydrotherapy department while still undergoing emergent management for acute heart failure. This required a large whirlpool tank, and the ER was not equipped. The initial task of removal and disposal of the sleeping bag was accomplished and a final rinse of the patient was completed. The patient was then draped in blankets and an area was identified as needing immediate treatment. The area itself was prepared for initial debridement and dressing.
During the process, we witnessed an interesting transformation in the patient’s personality. The patient began to open up and started to talk to us, providing valuable feedback. The clean blankets and gown changed everything for this patient. We were learning about his family and support systems, and the outlook became increasingly positive. We were completing the wound care process when the lead resident stomped into the hydrotherapy room without a knock and with the door left wide open behind him. He tossed the patient’s chart onto a table, missing badly. The result was that the chart fell to the floor, breaking open with pages sprawled about the damp floor. He proceeded to rip verbally into the patient, “What’s the matter with you? Why are we wasting health care dollars on you? You are not worth my time. How much time am I going to waste walking up here when I could be helping people who deserve it? My time would be better spent playing golf!" He left, slamming the door, while we had our hands full of gauze. The patient retreated into mute silence.
The damage accomplished in such an interaction cannot be measured. Degrading language may work on the field of play for some, but in the clinic of real life and especially for those with psychological sequela, degrading language is doomed to failure. When that doctor walked out of the room, he not only left us with a mess on the floor, which took time away from patient care, but he also destroyed a tenuous rapport for anyone in a white coat. The patient stopped talking but communicated a larger-than-life message in silence.
Regardless of how much you try to have a positive interaction, when an event is followed by a negative interaction, the patient rapport will be sabotaged. As a healthcare provider, I would always be associated with that one doctor. In fact, for that patient and the related family, every healthcare provider or person bearing a white coat will be associated with that negative event. It is no wonder some patients avoid honest interaction. Degrading language and negative behavior by a professional has never improved the behavior of a patient demonstrating a profound baseline self-care deficit. So why do it? Perhaps negative behavior by a professional has more to do with the professional who is directing the assault than it has to do with the patient. The consequence of degrading language is diminished communication with the patient and the patient’s family and a subsequent prolonged length of stay. It undermines cost effective progression of the patient to the next level of service.
This is not a discussion to promote an inflexible, politically-correct work environment. Rather, the discussion is to drive home the point that the cost of a negative care environment affects us all. Negative conduct results in increased cost for everyone. It is odd how some professionals can so fully understand that the use of degrading language toward a patient who has a diagnosis of Alzheimer’s serves no purpose, but on the other hand demonstrates little respect for those with other identifiable psychological propensities.
I recall a question posed by a nurse at a recent conference. She asked, “Why can’t we use degrading language about a patient behind closed doors?" I was bit surprised by the question. It was entirely innocent, but still points to a larger issue among some caregivers. I responded, “You are free to say whatever you want behind a closed door, but ultimately whether you are positive or negative reflects upon you.”
Patients will judge whether or not a person is sincere. When a caregiver trashes a patient in a conference or lunch room discussion and then walks into the patient’s room with a fake smile and phony façade, it is obvious to the patient. Most patients are very perceptive and are able to detect insincerity. A positive work environment is needed in health care to move the patient to the next level of care in the most cost-effective manner. That can only be done when the providers are sincere.
As nurses and therapists all know, a good rapport is everything. Many support personnel become masters in achieving a good rapport when working with their patients and are able to accomplish miracles -- tasks that the credentialed professional could not. We must reinforce the value of every member of the health care team as well as the value of a positive approach.
The De-Activated Society and Stereotypes
For many professionals obesity is still simply a behavioral disorder. The behavioral sciences began with the studies of Sigmund Freud, and collectively refer to psychology, sociology, and anthropology. They derive their theories and methods from the study of the behavior of living organisms. Human behavior has been studied closely since that time. However, obesity as a pandemic explosion has statistically existed only since about 1990. Obviously, there is more to the accumulation of size than simply just behavior.
Europeans are now starting to feel the effects of metabolically-suppressed environments. We recognized that if astronauts do not exercise while in space, they will lose muscle mass and bone density. While in the weightless environment, cardiac output and pulmonary function can become so weakened over time that severe sickness and potential system collapse can result. Resistive exercise is required of the astronauts if they are to survive. As technology progresses to a level where it dominates our lives, we must change our culture to include activity in our daily lives to elevate our heart rate. The consequences of inactivity are catastrophic.
Compare the lifestyle of a 1960s child to that of a child of the new millennium. When I was a kid if I wanted to play, I would grab a bunch of my dad’s tools and screw some roller skates to a plank and call it a skateboard. Today’s kid slides a CD-ROM into a computer and uses a mouse and video game to occupy his time. If my father wanted to change the TV channel, his only remote was me. I had to get up from the couch, make my way over to the TV, and turn that big knob that changed the channel. It was a task that took two hands that often left marks on my skin. That was on a good day. If the knob was broken, then I had to get the old pliers to turn the metal nub that remained. Because I walked across a wool carpet, I was charged with electrons; and, upon contact, I got zapped. After I fell to the floor in heart arrhythmia, my dad would run over and grab the old rabbit ears antenna, plug it into the wall socket, and touch the antenna to my chest and perform electric cardioversion. I survived, never mind a little smoke rising from my chest. To minimize the static on the TV screen, Dad would direct me to run around the room with the rabbit ears antenna balanced on my head.
Admittedly, it is a relief not to run around the room with the rabbit ears anymore, but the point is that currently we are not burning calories in even the most basic activities. Too many children sit on the couch with an infrared remote and surf 200 channels succumbing to a blank expression and depressed brain activity. We are deactivating our society with video babysitters. As a kid, I played on monkey bars, swing sets, merry go rounds and horizontal bars that were built on cement. If you fell, you split your head open. The teacher simply told you to tuck your brain back into your head and get back into school. Our slides baked in the sun all day, and you fried your backside on the way down or jumped off the side, breaking an ankle. Today, a child uses a slide made from tubing where falling is not possible. The greatest fall is about twelve inches into soft wood chips.
When I was a kid crossing the city of Milwaukee on a bus in 1970s, you could hear the sound of construction workers using jack hammers and you could watch them working with their tools. Much of the work in digging was done manually and employed a shovel and pick axe. Now, construction workers have use of smaller powered backhoe devices that attach the jackhammer to a miniature bulldozer to do the work. None of us are burning calories anymore. The Segway ® is now on trial in postal districts and is anticipated to revolutionize efficiency in delivery. Obviously, the body weight of postal workers is going to explode when such energy efficient tools are employed.
It is ironic that OSHA (U.S. Department of Labor Occupational Safety and Health Organization) and lawsuits instigated by injury claims are making working environments safer, but are resulting in depressed metabolic rates. It is not my intention to suggest that we should not maximize efficiency and safety in industry. We need to recognize that we are becoming trapped by our own technology and that it is killing us in terms of metabolic suppression and its ultimate consequences, like diabetes.
Because of lawsuits related to falls on public steps, architects now create buildings that direct patrons to an escalator or elevator. If you can find the steps in a large building, often the walls are left bare and unpainted as they are so rarely used. The result, of course, is greater safety, but the consequence is a generation of people who very rarely take the stairs. It is amazing how many people in airports stand idle on the mobile walkways. They are great for those who need them; but, when you see an obese child drinking a large soda and standing idle on such a walkway, it begs the observer to ponder the implications of technology and diet as it relates to that child’s life expectancy. We need to rethink how we play and how we work.
Another question I pose to American audiences is, “How many of you believe Americans are lazy? Please raise your hands." Usually this will draw at least half of the participants in the room to raise their hands. I ask them, “How many of you know a nurse or an aide who has worked a double shift?" Almost all hands go up. “How many of you know of someone who works a side job or two jobs to make ends meet?" Again, about half of the hands go up. Then I ask, “If you lived in France or Germany, how many hours would you be limited to work in a week?" When I tell them the answer is 35 hours per week, my audience is usually shocked. They are equally surprised to hear that these people also receive as much as four to eight weeks of pure vacation annually. Because of the economic dynamics of employment in the U.S., most Americans are lucky to see more than one or two weeks of vacation in a single year. Americans simply work more hours than people in most other nations.
I was asked once, “What about that poor farmer pulling the grain out of the earth with his bare hands?" I agreed that these people do work very hard, but compared to the average American farmer, it is no contest. He often works an eight hour shift in a factory or in construction then returns to his farm and jumps into a machine as big as my house and farms until two in the morning. He goes to sleep only to wake at six to do more chores so that he can be at work by eight. Farmers work an incredible number of hours in the U.S. as do many farmers in other countries; the difference is American farmers drive massive combines through the night while farmers in less developed countries often use manual technology and take their rest. The American farmer fills the cab of his air conditioned tractor with soda or coffee and snacks to stay awake to meet the day’s goal. We truly have a bit of a self-destructive work ethic in this country. We live to work.
Recently, I stayed in Chicago to do a series of safety programs. Because of the cost of hotels, I stayed out by the O’Hare Airport and I had to wake up at four-thirty to be to downtown by eight. This kind of commute causes three and a half hours of total driving each day or seventeen hours for the week. There is a whole population of Americans who have not sustained aerobic activity, even walking, for thirty minutes in months. Sadly, this includes children. If you placed a video camera in the streets of Tokyo, Beijing, Berlin, Copenhagen, London, or any large city outside of the United States, you would see folks riding trains, buses, bicycles, walking and carrying objects to work. The point is that their cities are old, and cars are difficult to use there. Our cities are newer and planned with cars in mind. In fact, we park just a few feet from our kitchen door in the attached garage, a luxury unheard of in many older cities.
Once at work we walk a couple of hundred yards from the car only to sit at a computer terminal in our office for most of the next eight to ten hours, taking a few breaks only to eat. At the day’s end, the employees walk the short distance back to the car, unlock it, make the one-and-a-half hour journey back home through a sea of traffic, and go into the attached garage with a simple press of the garage door opener. We eat dinner, and sit in front of the television for a moment to catch the news using the infrared remote. It is now nine o’clock. Before bed, we help our kids with homework and check our e-mail. Someone working late at the office has sent a quick message, and it is returned before bed. This is a lifestyle that is progressively deactivating all of America. Americans are not lazy. We are deactivated. Consequently, we spend far too little time with family or performing cardiovascular activity. We need desperately to incorporate activity into our lifestyle to become healthier. It is a shame that Americans are losing so much of the very quality of life we all work so hard to improve.
Societal perceptions of obesity remain mostly negative. It is perceived as a hand-to-mouth disease, a behavioral disorder, or just laziness on the part of the entire population. There is, for example, no doubt that there are lazy people among us, and lazy people come in all sizes. I ask participants of our programs to assess the overwhelming video evidence where persons of size fight for independence. After our program, participants come away with the new view that confirms that most persons of size are not lazy. A lazy person simply never makes the attempt. What I portray is a view where individuals fight for success over adversity.
I often recount the response a professional once made when we observed a patient fabricate a shelf across his walker to support his abdominal mass. The professional said, “Man, how lazy do you have to be!" Frankly, the innovation was an exercise of intelligence. If the patient were truly lazy, he would have stayed in bed and retreated from the difficult task of walking. This patient smartly tripled his walking distance by reducing the workload of the activity.
If obesity is strictly a behavior disorder, then we must examine the compelling story of the deadly rise of diabetes experienced by the Pima Indians of Arizona. The Pima tribe members work every bit as hard as their European-descent counterparts. However, their bodies had adapted to a level of efficiency over the generations to survive in the desert. In fact, they can survive in the desert for two days without food. Most of us cannot. The Pima are genetically adapted to a high level of metabolic efficiency for their environment. (2) Now, as productive members of the modern era, the Pimas’ physiology is incompatible with the modern diet. They work just as hard and side by side with their European counterparts, but the great difference is that the impact of computers, infrared TV remotes, vehicles, and a modern fatty diet has had a devastating result for the Pimas. They now suffer an average onset of diabetes as young as age seventeen. I believe it is an error to advance the notion that all people who tend toward size are lazy. Too many groups have suffered from the stereotype in spite of the many contributing environmental factors.
Past struggles for patients of size making their way through the healthcare system is a study of a unique patient population requiring unique intervention. Acute care and outpatient management have dramatically improved; rehabilitation and long-term care remain a pressing issue. Mobility challenges are always present for those of size who are dependent making an effective equipment prescription a must. Embedded in the interdisciplinary features of rehabilitation is a diversity of unique presentations within the population of size. Patients must be addressed as unique individuals (rather than as a group) in order to safely and effectively treat this often underserved patient population. Bryan Woodward provides a possible solution in A Complete Guide to Obesity Surgery; he writes that millions of people have given up on diets and have chosen to undergo surgery in hopes of a better life. (3)
As I developed more experience in working with those of size, I developed greater respect for the human aspects and the amazing possibilities that this work could provide. I began to read and research this epidemic. An epidemic is the occurrence in a community or region of cases of an illness, specific health-related behavior, or other health-related event, clearly in excess of normal expectancy. As always, there are contributing societal issues underlying the epidemic. It would be a misinterpretation to view people of size as the problem itself. However, this knowledge gives us a new and more positive way to look at the statistics. The growth in the population of people of size has exceeded the unprecedented polio epidemic, which peaked in the summer of 1952 with almost 60,000 cases. This point has been driven home in the course of conversations with reporters who ask me to describe diversity in the population of size. In an interview with one journalist, I remarked that my challenge had become to articulate the accomplishments that both the patient of size and his healthcare provider are achieving despite a medical industry that is scrambling to meet the needs of those who are of significant size. Sometimes medicine gets sidetracked by the latest study du jour. Without needing to elaborate further, simply look at the chart below. It is from the National Health and Examination Survey conducted by the National Center for Health Statistics. The National Health Survey Act of 1956 provided legislation authorizing a continuing survey of current statistical data on the amount, distribution, and effects of illness and disability in the United States. (4)
The pandemic explosion of significant size within the entire population reflects many contributing factors. For the first time, we have new patient populations such as the geriatric bariatric population. For the first time since 1998, I see survivability in this group. I have worked with a 70 year-old whose stomach was just four inches from the floor, and a person of 600 pounds who was 65 years old. In the late 1980s, if a person of 500 pounds or more spent four to six weeks on a ventilator for assisted breathing and acute management for heart failure, they typically had a life expectancy of about five years. Since that time, medicine and physician intervention has profoundly improved quality of life and has extended life expectancy of unknown limits. We can no longer anticipate the life expectancy for many patients of size. Many are now living well into their senior years. Some individuals are living with cardiac output and reflected ejection fraction as low as 25%, which is considerably lower when compared to a senior 75 years-old within the 40 to 60% ejection fraction range.
Predictions indicate that nearly 100% of the US population will be either overweight or obese by the year 2030 at current rates. (5) Clearly, this topic is only going to become more important. This book provides a guide in your exploration of how the entire medical community has had to develop new expertise in the management of the severely dependent obese patient.
Chapter 2. Clinical Perspectives in the Management of the Patient of Size
The problem of addressing clinical management for those of size is a perspective of cost. Let us start with the big picture: from an industry standpoint, the patient who is overweight will stay as much as one-third longer per diagnosis. According to a Harvard Medical School survey, their stay reflected costs 30% more than for patients of low risk body weights. (6) The Harvard study included 365 patients, mainly in their sixties, and mostly women, who had total knee or hip replacements. The extremely overweight patients averaged 29 days in the hospital.
The results of these longer stays become very obvious in financial cost to all Americans who pay escalating insurance premiums. Too often for the population of significant size, the human costs are devastating. For those of significant size, the reasons for increased length of stay in the medical system may include increase frequency of co-morbidities. In the general population, the healthy group comprises those who are at about the 90th to 110th percentile on a weight index table. Moving to either spectrum of size below or above that healthy percentile, a dramatic increase in contributing pathology becomes apparent. The following list is just a few contributing factors that may contribute to prolonged length of stay for the population of size.
Pickwickian Syndrome: a combination of significant size, somnolence, and general debility, resulting from hypoventilation induced by obesity. The patient may require additional time for training in how to use any issued equipment. (7)
Asthma: an inflammatory disease of the lungs characterized by reversible airway obstruction. Often, medications related to weaning take additional time to resolve.
Respiratory Acidosis: caused by a retention of carbon dioxide due to inadequate pulmonary ventilation or hypoventilation. Indeed, we often refer to these people as “CO2 retainers."
Bronchitis: inflammation of the mucous membrane of the bronchial tubes.
Oxygen Desaturation: the loss of oxygen in the blood stream.
Sleep Apnea: characterized by frequent awakening and daytime sleepiness. The airway collapses or becomes diminished in heavy people, causing snoring and the cutting off of air. This resistive airway syndrome results in hypoventilation syndrome.
Diabetic Training: At a 140% above average body mass there is a seven and a half fold increase in the prevalence of insulin dependent diabetes. Many patients will require extra time to become well titrated with regard to their insulin use and educated in diabetic training.
Weakness Relative to Body Mass. If a client fractures a hip, the patient may undergo some level of fixation for the affected hip and a period of restricted weight allowed on that hip. For the patient of 160 pounds, typically they are allowed to bear about half of their body weight, being about 80 pounds. The patient likely could learn to walk with an assistive device such as a walker about fifty feet in a few days. In the United States, we refer to this as partial weight bearing. However, if the patient weighs significantly more than that, it is unrealistic to believe that the patient could support their weight in this fashion.
If a person is of size and becomes dependent after a bout of heart failure, too many professionals would expect the patient “to suck it up and control your urges." Obesity has many contributing factors, and overeating is just one of them. I recall one study that referenced “The Purdue University Jelly Bean Study” in 2000 as sited in the Journal of the American Osteopathic Association that pointed out consuming 200 milligrams of sugar from a can of soda actually stimulated one’s appetite, because of the caffeine and sugar. Put the same caffeine and sugar into the form of something solid, like a jelly bean, and the solid will suppress appetite once feedback mechanisms become stimulated. The liquid has far less impact in a feedback response. The impact of constant exposure to high sugar beverages such as fruit juices and soft drinks cannot be understated given the explosion of obesity and diabetes among this population. Adults need to exercise responsibility in diet for their dependents. It is the children who have the least grasp of the consequences of poor diet. (8) (9)
The implication is if two groups of children are placed into separate rooms, an unlimited amount of sugar in the form of a jelly beans was provided. In the other room is an unlimited amount of soda. The children attempting to eat a comparable amount of sugar and caffeine in the solid form of the jelly bean became self-limiting to about 20 minutes of continuous consumption. The children who were provided an unlimited amount of soda were not self-limiting and continued in their consumption activity. The deadly reality should be obvious when you see small children who consume large amounts of soda several times daily.
Sadly, milk consumption is on the decrease. Milk is clearly more filling and beneficial as an age-appropriate beverage providing calcium for a child. The 1960s child actually liked and asked for a glass of milk with cookies. A child in the new millennium often will express preference for soda over milk and will usually get it. The decision of whether to have exposure to sugar-based products is a huge responsibility for parents. I believe it serves no one to sue fast food providers for the current pandemic of obesity. On the other hand, it is extremely frustrating to ask for a carton of fat-free milk and be told by a fast food restaurant that they will charge you additionally for the milk rather than substitute the product in place of soda. Certainly if consumers would demand fat-free milk, the market would adjust; the prices would become more economical.
If you have a color TV, car, or cell phone, you are considered to be living in the top one percent of the world’s income. In the United States, those who are defined at the poverty level have skyrocketing obesity rates. Ironically, the wealthy are having the same problem. Their stomachs are having a hard time fitting into the driver’s seat, which leads them to buy vans and SUVs. The best way for all consumers to have a voice is to take personal responsibility in what we choose. We need grassroots activism.
For children, rules and discipline can become healthy guidelines and boundaries in all aspects of our lives. This is true of the food we select, the activity in which we participate and the choices we make throughout the day. We need to plan into our routine times when we make the choice to walk or take the steps. If we want to watch TV, we should do it while we are riding a stationary bicycle. We need to show our children that being physically active is a priority.
The Feedback Mechanisms
Let us consider the calendar year: New Year’s Eve, Super Bowl Sunday, Valentine’s Day, Easter, Mother’s Day, May’s graduation parties, Memorial weekend, Father’s Day, June weddings, July the Fourth, summer vacation, Labor Day weekend, the World Series, Halloween, Thanksgiving, Christmas, and other ethnic holidays or celebrations. On top of these, add personal holidays like anniversaries, birthdays, homecomings, proms, and so on. It is absolutely amazing to add up all the days in a year when we indulge ourselves to our physiologic limit.
Physiologists have not been able to isolate a specific mechanical stretch receptor in the wall of the stomach that would tell us we are full. Let us consider the feedback mechanisms we do rely upon to limit our intake of food. One is the sensation associated with eating too much, such as distention or bloating of the abdomen. Who can argue that the delicious taste of Grandmother’s Thanksgiving meal drove us to exceed our limitation in capacity? After eating such a meal, the last thing one would want to do would be to wrestle or risk taking a hit to the stomach. The very thought is uncomfortable. Just as a physician would use the clinical tools of palpation to localize stressed tissues or abdominal masses, you can elicit abdominal discomfort to confirm capacity.
The sensation of fullness or distention is also common in folks who develop large amounts of water within their abdomens caused from increased pressures within the circulatory pathways of their liver or increased pressures in vasculature on the right side of the heart. The result of higher pressures in these areas can cause the relocation of water from the blood vessels into the spaces between the tissues of the abdomen and peripheral tissues in the lower body. Excessive water retention in the abdomen is referred to as ascites. The ability to produce and exacerbate abdominal discomfort with direct palpation or compression in such an activity as leaning forward to tie shoelaces becomes prevalent. For the consumer, this is a powerful confirming signal that limitation of capacity has been reached. Just the thought of reaching your stomach capacity and the sensation of distention after eating can become very unpleasant. The feeling of fullness from distension is a strong proprioceptive feedback mechanism. The feeling of bloating or distention is very meaningful for either the patient with liver failure or a person who has just consumed a large meal.
Cholecystokinin (CCK) and pancreatic polypeptide (PPY) are chemical messengers that communicate to the brain and regulate food intake. Both PPY and CCK are distributed in the gastrointestinal tract. These hormones are released primarily from the first two segments of the small intestine. Hormonal endocrine mechanisms rely mostly upon transport to the target tissue via circulating blood. As food leaves the stomach during initial digestion, it passes into the duodenum and the jejunum respectively. In gastric bypass, the duodenum is most commonly bypassed as the capacity of the stomach is directed to the more distal aspects of the small intestine such as the jejunum or ileum. In the duodenum, hormones are produced by the intestinal mucosa in two forms. CCK and PPY are neurotransmitters released into the bloodstream during digestion. The hormones travel in the bloodstream and stimulate their respective target receptors. PPY appears to have its greatest effect directly in the brain via the bloodstream. Specific action is in the hypothalamus of the brain resulting in suppressed appetite. The hypothalamus is a deep control center within the brain responsible for regulating many of our most basic life functions. There are fascinating studies that have shown promise in appetite suppression. In one study, researchers found that by injecting individuals with the neurotransmitters PPY and CCK prior to eating, the participants experienced a reduction in appetite. Vagotomy was found to block the effect of CCK on food intake, indicating that gastrointestinal hormone CCK regulates food intake primarily through the stimulation of the vagus nerve rather than through purely direct endocrine mechanisms. (10)
For now, one cannot disregard the feeling of fullness and distention as our most meaningful feedback mechanism. We can also go a long way toward appreciating the dilemma for those who lack such feedback mechanisms and understand why diet alone fails 85% of the time. I believe we rely mostly upon mechanoreceptor stretch receptors located in the subcostal rib and/or abdominal soft tissue regions. We simply ache about the subcostal or abdominal regions when we fill our stomachs to capacity. When you hear the phrases “distended,” or “stuffed to the gills” used, you know exactly what is being expressed. This is a discomfort caused by overfilled capacity. To add more would be painful. More importantly, it is separate from the issue of CCK, which stimulates the brain to decrease appetite.
Another feedback mechanism not given enough credit in limiting our capacity is the feeling of esophageal acid reflux. Certainly, the anti-acid manufacturers are aware of the phenomenon around the holidays. The anti-acid producers increase their advertising efforts, marketing budgets and production from Thanksgiving through New Year’s Day. They know our feedback mechanisms better then we do as they scramble to meet the demands of the free market.
After Grandma’s great Thanksgiving Day dinner comes the inevitable pumpkin pie. One year, my grandma set ours on the back steps to cool. She went out to retrieve more supplies from the basement and stepped in the pie. At the age 85, Grandmother baked everything from scratch which meant she began planning for that pie some four months before. Grandmother was also an innovator. She filled the footprint of the pie with whip cream to “cover her tracks." Fortunately, she served two pies that day and confessed with a smile.
The younger generations are losing the baking skills of their grandparents. This reflects a dramatic cultural shift in our food selection from a time when foods were created by scratch with lower amounts of salt and sugar. Today’s convenience foods are ultra-high in calories, sodium, and fat. For many, much of their weekly diet is processed and fast foods. Would our ancestors be overwhelmed by the richness of today’s food and would the generation of the pilgrims find our food too sweat or salty?
Imagine that you are full to capacity, distended. The base of your esophagus begins burning. In this situation, most people seek out a semi-flexed posture, like in a recliner. Most avoid flat or inclined postures such as bending over to tie their shoes. These activities greatly worsen the sensation of abdominal compression and reflux. Many folks will reach for the anti-acids at this point seeking relief for upset stomach and the burning reflux sensation. As many people agonize in this miserable condition only a few times a year, it is a perfect example of the three feedback mechanisms at work: PPY and CCK release, distention, and reflux.
Statistically, Apple Distribution is associated with the late in life onset of obesity. Consider the case of a construction worker who, in the course of a day, burns lots of calories. Some people are drawn to such occupations. They may have even been larger athletes in high school, performed well in college sports, but found the realities of professional sports an unlikely vocation. Given their tendency toward a powerful size, construction becomes a perfect match for this person’s physical attributes. The construction worker has an hour scheduled for lunch, but like most hard-working Americans, he only takes fifteen minutes of it. This level of motivation toward work is very common in health care and factories where workers are paid based upon productivity and construction. It really has become a joke to ask how many people actually take two breaks and a full lunch in today’s job market. We do it to ourselves. As a result of ever-intensifying job performance demands, many Americans maximize caloric intake in a short period of time, and subsequently stretch their internal capacity when they do eat. It is important to understand that professions based upon productivity greatly influence the feeding habits and physiologic adaptation of those who work in those environments. Long-term consequences may result in stretched capacity, gulping reflexes, and greater gastric emptying. When these influences are combined, the person is devastated with a disadvantaged feedback mechanism. Capacity becomes maximized when individuals take larger meals in an attempt to minimize their time away from the actual work. Many think nothing of consuming a foot-long submarine sandwich, chips, and huge soft drink in order to make it through the work day without having to eat again. Portion control becomes lost. For years this cycle works for these individuals as their bodies adapt to the intake of massive calories.
Let us fast-forward to a time when such individuals diminish their activity, typically in their later forties. Many reach positions where they are no longer as physically active. These promotions put them in front of a computer and at business lunches. At this time, the consequences of adaptive intake begin to sabotage the individual’s capacity to limit intake. A patient of 400 pounds may have a gastric capacity of over a gallon, more than double that of the average sized person. Feedback mechanisms for normal capacity become devastatingly compromised. They feel hungry long after averaged-sized persons have reached their limits.
Many persons of size form a significant drift of their abdominal wall inferior-ward as the fascia, skin, abdominal and trunk muscles become stretched and herniated to a level well below beltline. This region of the abdomen is referred to as an apron, pannus or panniculus. After gastric bypass, the post-operative patient may sustain up to 70% of body weight loss for up to ten years yet retain this inferior drift of the excessive abdominal wall tissue. (11) The stomach and surrounding fascia do not shrink back to their original location. Surgical reduction or removal known as an abdominoplasty, pannus reduction or tummy tuck is required to prevent potential health risk related to moisture retention, hygiene and tearing of the pannus.
Understanding the consequences of lost feedback mechanisms helps explain why some folks may feel hungry or lack the sensation of fullness where the average-sized person would feel distention. It is very interesting to watch the great successes played out with gastric by-pass and Lap-Band placement now succeeding, with a success rate of up to 54% sustained weight loss over ten years. Gastric by-pass is performing far above the meager 15% five-year success rate of diet alone. (12) I cannot think of another medical intervention that would be reimbursable at a meager 15% five-year success rate, yet the diet industry is a multi-billion dollar industry and growing every year. This is an issue that goes way beyond will power. Since the pandemic growth toward size hit the United States in the early 1990s, there are too many good people who try to keep the weight off only to fail in the diet experience that stereotypes them all as lazy. Long-term studies set the national rate of weight-loss failure with diet alone as high as 85%.
It is interesting how many average-sized persons who exercise regularly fight to lose weight in order to fit into a wedding dress, to enter a dance or wrestling competition, or to prepare for medical exams or religious events. These are often some of the harshest critics of those of significant size. These same average-sized critics know how hard it is to get the weight off, and in some cases, even know the burning feeling of hunger that develops just below the ribs. Yet, these same people will criticize their sizable counterparts who manage to lose the largest amounts of body weight as having lacked will power. The hypocrisy lies in the fact that the average-sized person has a functional feedback mechanism and cannot imagine the challenges that significant-sized persons battle every day.
When I lost weight (from 160 pounds to weight divisions as low as 138 pounds) for a Judo tournament, I would see food at a distance and the visual stimulus would cause me to imagine the smell and taste of the food. The difference between the average-sized person and the significant-sized person was that there was relief at the end of the event, and I could eat to capacity. My average-sized capacity, empowered by my intact feedback mechanisms, prevented pathologic intake. For those of significant size, there is no such feedback. It is a day to day battle.
The myth of willpower is overplayed. I recall Dr. Phil McGraw of TV talk show fame being interviewed on Larry King Live one night. He was talking about obesity and correctly stated that obesity has many causes. Ultimately, we will have to respect the challenge and the courage required to change our behavior as a culture to maximize health if we are to succeed in reversing the tendency toward size. The challenge to lose weight varies greatly from person to person.
I recall a psychologist state that “this is solely a behavioral problem." Of course, as a clinical psychologist, the only paradigm he has is that of behavioral issues. If a patient suffering from back pain goes to a surgeon, surgery will likely be prescribed. If the same patient goes to a physician whose background is medicine, he will obviously prescribe medication. If the same patient goes to a chiropractor, he will get orthopedic manipulation and electrical stimulation. If he goes to a physical therapist, he will get postural-related exercises. If that same patient goes to a clinical psychologist, he will get behavior modification and coping mechanism instruction. All of these things are helpful and succeed as parts of a comprehensive team approach. However, to suggest that obesity is solely a behavior problem falls apart when you consider that behavior has been around for thousands of years. The pandemic explosion of obesity began in 1990. There is simply more to the explosion of size than to suggest obesity is solely a behavior disorder.