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Obesity in Long Term Care: A Multi-Level Understanding

  • abissett22
  • Jun 27, 2022
  • 6 min read

Updated: Jul 4, 2022

A multi-level model of health provides valuable insight when applied to a specific health issue, such as obesity in long term care. The Dahlgren & Whitehead model of health determinants suggests multiple levels of determinants of health: individual factors, social and community networks, living and working conditions, and general socio-economic, cultural, and environmental conditions (Dahlgren & Whitehead, 1991).


It is clear that the overall health of long term care residents with obesity is significantly impacted by factors at every level. In this blog post, I will examine challenges at each level and summarize evidence based recommendations. Figure 1 is a depiction of the model we will work through in this blog post.

Contributing Factors and Impacts of Obesity

Obesity is a complex, multi-factorial condition. There is a pervasive cultural myth that because lifestyle factors contribute to obesity, this disease is within the control of the individual. This belief leads to weight bias, stigma, and discrimination (Alberga et al., 2016; Puhl & Heuer, 2010; Wharton et al., 2020). My hope is that this blog post can demonstrate some of the key contributing factors and impacts of obesity, and can help the reader develop empathy for individuals impacted by this condition.

Individual level: There are several key genes that can cause a predisposition to obesity (Loos & Bouchard, 2003). Obesity is also associated with many other conditions, such as diabetes, cardiovascular disease, hypertension, arthritis, pressure injuries, renal failure, and wound infections (Harris, Enberg, & Castle, 2018). Although not solely responsible for obesity, lifestyle factors can contribute to the development and severity of the condition. Unfortunately, obesity can contribute to the development of lifestyle factors that worsen the obesity, causing a cycle of advancing disease. Obesity is associated with chronic pain (Janke, Collins, & Kozak, 2007), including osteoarthritis, knee pain, and low back pain (Forhan & Gill, 2013). There is also a tendency for people with obesity to adapt their gait due to changes in weight distribution, leading to decreased walking speed (Forhan & Gill, 2013). Additionally, people with obesity are at higher risk of mobility impairments, falls and injuries than the general population (Forhan & Gill, 2013). Pain, gait changes, mobility impairments, and fall risk can all lead to lower levels of physical activity. Obesity and mental health can be inter-related. The symptoms of mental illnesses, as well as the medication used to treat them, can both contribute to obesity (Davies, 2016). To top it all off, weight bias can actually lead to avoidance of exercise and increases in unhealthy eating habits (Alberga et al., 2016).

Social and community networks: Social networks can provide support, meaningful connections, and improve our mental health. They can also reinforce lifestyle choices and impact how we feel about ourselves. For people with obesity, some social situations can lead to embarrassment (Pories & Rose, 2017). The literature also shows that people with obesity may experience discrimination not only from strangers, but their own peers, family members, and friends (Kopelman, Caterson, & Dietz, 2010).

Living and working conditions: For the purpose of this blog post, I will focus on the relationship between obesity and living in long term care facilities. If someone with obesity has difficulty living independently (either due to effects of the obesity or due to other medical conditions), long term care admission can be challenging. People with obesity who require long term care tend to be admitted at a younger age and spend a greater portion of their life in care than the general population (Harris & Castle, 2019). They are often confronted with barriers to admission including inadequate physical space, lack of necessary equipment, and mismatch between care needs and staffing model (Harris & Castle, 2019). Providing personal care for someone with obesity can take more effort, more time, and/or more caregivers (Harris & Castle, 2019). The literature also shows that obesity stigma negatively impacts quality of care (Wharton et al., 2020). In care settings, people with obesity can experience ambivalence from health care providers, dehumanizing and disrespectful treatment, health care providers' lack of training, attribution of all health concerns to weight without further investigation, and delays and barriers to accessing services (Alberga et al., 2019).

Cultural factors: Weight bias can impact the individual with obesity at every level of this model. The cultural view that the sole responsibility for obesity lies within the individual is harmful. Weight stigma creates risks to mental and physical health (Puhl & Heuer, 2010). Stigma may actually be the cause of some of the negative health outcomes associated with excess weight, including anxiety, depression, low self esteem, and even mortality risk (Alberga et al., 2016).

Figure 2 provides an summary of this information and demonstrates multiple causes and impacts of obesity at each level of the model.


Strategies and Recommendations

While the complexity of obesity and the many factors involved can be discouraging, there is hope to improve health and quality of life outcomes. There is a growing body of evidence for strategies and recommendations at multiple levels. Figure 3 highlights several key strategies at three levels: individual, long term care environment, and cultural factors.





Individual Level: Current literature supports a focus on health and well-being, rather than weight (Wharton et al, 2020). In addition to addressing diet and exercise, practitioners should address barriers to functional mobility through strategies such as energy conservation and/or mobility devices (Wharton et al., 2020). Multi-disciplinary intervention is beneficial in areas such as nutrition, exercise, psychological/behavioral interventions, pharmacotherapy, and in some cases, bariatric surgery (Wharton et. Al, 2020).

Long Term Care Environment: For many years, there has been a call for enhanced injury reduction programs, staff education, interdisciplinary and sufficient staffing complements, adequate equipment, and modified physical environments (Bradway et al., 2008). There is evidence to support increasing staff ratios; Cai, Rahman, & Intrator (2013) demonstrated that there is less of a discrepancy between pressure injury risk of obese and non-obese residents in facilities with higher staffing ratios. More recently, strong recommendations have been made for health care providers to examine their own beliefs, confront their own biases, and engage in respectful conversations about obesity (Pories & Rose, 2017). Alberta Health Services has published recommendations for bariatric friendly hospitals (AHS, n.d.) which apply to other care settings as well. These recommendations include respectful interactions, knowledge of unique care needs, recording all patient weights close to the time of admission, and access to equipment and supplies. Another very helpful document from Alberta Health Services is an algorithm to individually assess bariatric care needs (AHS, 2018). I've used this algorithm in practice, to guide conversations regarding transfers from acute care to long term care. In my experience, it has been a useful tool for concise, comprehensive screening to ensure patients are matched with the services they require. In addition to this tool, I would also suggest screening for psychosocial care needs.

Cultural Factors: Obesity stigma and discrimination have extensive impacts on an individual's health and wellbeing. There is a need to increase public awareness about the complexity of obesity, as part of anti-stigma efforts. Prevention efforts must not only individual factors, but also societal causes of obesity (Puhl & Heuer, 2010).

Moving Forward

Obesity is clearly a complex condition, and meeting the care needs of individuals with obesity can be challenging for several reasons. In order to improve health and quality of life in long term care and other practice areas, clinicians must be armed with a multi-level understanding of obesity and evidence based recommendations. Above all else, clinicians must have respect and compassion for all individuals we serve, including individuals with obesity. As a society, we can and must do better by confronting our own biases and treating our fellow humans with dignity.


References


Alberga, A.S., Edache, I.Y., Forhan, M., & Russell-Mayhew, S. (2019). Weight bias and health

care utilization: A scoping review. Primary Health Care Research and Development. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6650789/


Alberga, A.S., Rusell-Mayhew, S., von Ranson, K.M., & McLaren, L. (2016). Weight bias: A

call to action. Journal of Eating Disorders. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5100338/


Alberta Health Services (n.d.) 7 standards for a bariatric friendly hospital.


Alberta Health Services (2018). Bariatric care needs assessment algorithm.


Bradway, C., DiResta, J., Fleshner, I., & Polomano, R.C. (2008). Obesity in nursing homes: A

critical review. Journal of American Geriatrics Society. https://agsjournals.onlinelibrary.wiley.com/doi/abs/10.1111/j.1532-5415.2008.01821.x


Bradway, C., DiResta, J., Miller, E., Edminston, M., Fleshner, I., Polomano, R.C. (2009).

Caring for obese individuals in the long-term care setting. Annals of Long Term Care. https://www.hmpgloballearningnetwork.com/site/altc/content/caring-obese-individ


Cai, S., Rahman, M., & Intrator, O. (2013). Obesity and pressure ulcers among nursing home

residents. Med Care; 51(6): 478-486. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3654390/


Davies, N. (2016). Mental illness and obesity. Psychiatry Advisor.

https://www.psychiatryadvisor.com/home/conference-highlights/aaic-2015-coverage/mental-illness-and-obesity/


Harris, J.A., Engberg, J., & Castle, N.G. (2018). Obesity and intensive staffing needs of

nursing home residents. Geriatric Nursing. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6281754/


Harris, J.A., & Castle, N.G. (2019). Obesity and nursing home care in the United States: A

systematic review. The Gerontologist. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6524472


Janke, E.A., Collins, A., Kozak, A.T. (2007). Overview of the relationship between pain and

obesity: What do we know? Where do we go next? Journal of Rehabilitation Research and Development. https://www.rehab.research.va.gov/jour/07/44/2/pdf/janke.pdf


Kopelman, P.G., Caterson, I.D., & Dietz, W.H. (2010). Clinical obesity in adults and children

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Loos, R.J.F, & Bouchard, C. (2003). Obesity - is it a genetic disorder? Journal of Internal


Forhan, M. & Gill, S.V. (2013). Obesity, functional mobility and quality of life. Best Practice &


Pories, M.L. & Rose, M.R. (2017). Reframing our view of the bariatric patient. Bariatric


Puhl, R.M., & Heuer, C.A. (2010). Obesity stigma: Important considerations for public health.

American Journal of Public Health. 100(6): 1019-1028. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2866597/


Wharton, S., Lau, D.C.W., Vallis. M., Sharma, A.M. Biertha, L., Campbell-Scherer,

D.,...Wicklum, S. (2020). Obesity in adults: A clinical practice guideline. Canadian Medical Association Journal. https://www.cmaj.ca/content/192/31/E875

 
 
 

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